Create and Assist in Implementing a Learning Dissemination Plan. The Plan should include dissemination of findings from the State-led Evaluation Study and overall State-led Evaluation results. The contractor will work collaboratively with Vermont on implementation of the plan. The following research questions will guide the VHCIP State-led Evaluation Study. The questions are organized into three themes identified as high priority by VHCIP stakeholders: Care Integration, Use of Clinical and Economic Data to Promote Value-Based Care, and Payment Reform. Care Integration. Integrated care is a key feature of many SIM-funded activities, and a major activity contributing to the goals of improving patient experience, improving population health, and reducing the per capita cost of health care. The majority of health spending is driven by patients with multiple conditions, multiple providers, and complex care needs. Nationally, there is a growing literature that defines frameworks for care integration and coordination, and recommends measures for assessing its effectiveness. The focus on care integration is meant to be broad to capture patient-focused, care integration/coordination activities performed by clinical and psychosocial providers. Across Vermont, care integration and coordination supported by the SIM grant takes a variety of forms, including, for example, identifying, reaching out to, and offering enhanced services to vulnerable populations at risk of admission to a nursing home; coordinating care for patients with particular diseases across a spectrum of social service and medical providers; improving care transitions to avoid hospital readmissions; and building on activities of existing community care teams. These models vary, but understanding the features of each that are most effective is critical to guide scaling up of care integration and coordination. The following research questions will inform Vermont in directing SIM-funded activities in this area: What are key examples of care integration approaches being tested/implemented across the state? What are the key characteristics of each approach in the sites that are studied, and how do they vary in evidence base, design, setting, focus, resource utilization, and cost, and in comparison to national care models? What evidence is available to demonstrate effectiveness of each approach? How solid is the evidence? What are the key lessons learned from each? What environmental and organizational features enhance care integrati...
