Common use of Extended and Functional CHTs Clause in Contracts

Extended and Functional CHTs. The Grantee shall coordinate the operations of the Core CHT (the staff supported by the funding from the insurance payers) with Extended and Functional CHTs and shall develop collaborative relationships between the Core CHT and the Extended and Functional CHTs as outlined in the deliverables below. The Extended CHT activities include Medication Assisted Treatment (Spoke staff), Support and Services at Home (SASH), and insurer and ACO care managers, including the Vermont Chronic Care Initiative (VCCI). The Functional CHT includes key local health and human services providers. The Grantee in collaboration with extended and functional CHT members shall document and inform the State of the: • Respective roles of the Core CHT, Extended CHTs, and Functional CHT • Clear referral protocols and methods of communication between the Core CHT, Extended CHTs, and Functional CHT • Well-coordinated and non-duplicative services for participants Medication Assisted Treatment Medication Assisted Treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance abuse disorders. The Grantee shall plan, coordinate, and implement the hiring and placement of (or subcontracting for) nurse case management and licensed substance abuse and/or mental health clinicians with local physicians who prescribe buprenorphine in the Grantee’s health service area. The MAT staff may be hired by the Grantee or subcontracted by the Grantee, as approved by the State. The MAT staff will work as a team with prescribing physicians to monitor adherence to treatment, coordinate access to recovery supports, provide counseling and health promotion services, and provide comprehensive care management to patients receiving MAT. The MAT staff will document their activities in the practice’s clinical record. In addition, the Spoke staff, with assistance from the Project Manager, will document the Health Home quality measures, participate in program evaluation, and participate in relevant learning collaboratives as determined by the State. The State will provide funds for one licensed nurse care manager and one licensed substance abuse and/or mental health clinician for every 100 Medicaid beneficiaries receiving buprenorphine prescribed by HSA physicians. The State will provide financing for MAT staff through the CHT payments mechanism. There will be no patient co-payments or fees for these services to assure barrier-free access to these services for patients and providers. Support and Services at Home (SASH) Under the Multi-payer Advanced Primary Care Practice Demonstration project (MAPCP), Medicare supports the Support and Services at Home (SASH) program as part of the Blueprint CHTs. SASH teams supplement core CHT functions by providing intensive, multi-disciplinary, team-based, non-medical wellness and coordination of care support to Medicare beneficiaries in Vermont. The Designated Regional Housing Organizations (DRHOs) administer SASH locally and are responsible for hiring and supervising SASH staff. Insurer and ACO Care Managers Care managers for both public and private insurers and ACOs supplement core CHT functions by providing clinical case management and support services to individuals identified as currently or potentially at risk for poor health outcomes and thus high healthcare costs. For example, the Vermont Chronic Care Initiative (VCCI) focuses on the highest cost Medicaid beneficiaries to assist them in better managing their healthcare. The Grantee shall ensure that all CHTs coordinate with insurer care managers and shall implement policies and guidelines requiring: • Determination of lead care coordinator for shared patients • Joint care plans and agreements for managing shared patients • Reciprocal referral protocols and methods of communication • Mechanisms for risk stratification and algorithms for determining which care managers will provide the care for which patient populations at what level of acuity Functional CHT: Interface with area health and human services agencies and ACOs The Blueprint Core CHT is a unique interdisciplinary team designed to support the general population. The Grantee shall help ensure coordination of care by supporting a Functional CHT consisting of key local health and human services agencies and ACOs, facilitating communication that reduces duplication of effort and enables the effective rendering of services. Key local providers include, but are not limited to, the local Home Health Agency, Designated Mental Health Agency, addictions treatment providers, Children’s Integrated Services (CIS) team, Enhanced Family Services (EFS) team, and ACOs.

Extended and Functional CHTs. The Grantee shall coordinate the operations of the Core CHT (the staff supported by the funding from the insurance payers) with Extended and Functional CHTs and shall develop strong collaborative relationships between the Core CHT and the Extended and Functional CHTs as outlined in the deliverables belowCHTs. The Extended CHT activities include Medication Assisted Treatment (Spoke staff), Support and Services at Home (SASH), and insurer and ACO care managers, including the Vermont Chronic Care Initiative (VCCI). The Functional CHT includes key local health and human services providers. The Grantee in collaboration with extended and functional CHT members shall document and inform the State of thedocument: • Respective roles of the Core CHT, Extended CHTs, and Functional CHT • Clear referral protocols and methods of communication between the Core CHT, Extended CHTs, and Functional CHT • Well-coordinated and non-duplicative services for participants Medication Assisted Treatment The State is collaborating with community providers to create a coordinated, systematic response to the complex issues of opioid and other addictions in Vermont. Medication Assisted Treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance abuse disorders. The Grantee shall plan, coordinate, and implement the hiring and placement of (or subcontracting for) nurse case management and licensed substance abuse and/or mental health clinicians with local physicians who prescribe buprenorphine in the Grantee’s health service area. The MAT staff may be hired by the Grantee or subcontracted by the Grantee, as approved by the State. The MAT staff will work as a team with prescribing physicians to monitor adherence to treatment, coordinate access to recovery supports, provide counseling and health promotion services, and provide comprehensive care management to patients receiving MAT. The MAT staff will document their activities in the practice’s clinical record. In addition, the Spoke staff, with assistance from the Project Manager, will document the Health Home quality measures, participate in program evaluation, and participate in relevant learning collaboratives as determined by the State. The State will provide funds for one licensed nurse care manager and one licensed substance abuse and/or mental health clinician for every 100 Medicaid beneficiaries receiving buprenorphine prescribed by HSA physicians. The State will provide financing for MAT staff through the CHT payments mechanism. There will be no patient co-payments or fees for these services to assure barrier-free access to these services for patients and providers. Support and Services at Home (SASH) Under the Multi-payer Advanced Primary Care Practice Demonstration project (MAPCP), Medicare supports the Support and Services at Home (SASH) program as part of the Blueprint CHTs. SASH teams supplement core CHT functions by providing intensive, multi-disciplinary, team-based, non-medical wellness and coordination of care support to Medicare beneficiaries in Vermont. The Designated Regional Housing Organizations (DRHOs) administer SASH locally and are responsible for hiring and supervising SASH staff. Insurer and ACO Care Managers Care managers for both public and private insurers and ACOs supplement core CHT functions by providing clinical case management and support services to individuals identified as currently or potentially at risk for poor health outcomes and thus high healthcare costs. For example, the Vermont Chronic Care Initiative (VCCI) focuses on the highest cost Medicaid beneficiaries to assist them in better managing their healthcare. The Grantee shall ensure that all CHTs coordinate with relationship between the core CHT and insurer care managers and shall implement policies and guidelines requiringshould include: • Identification of care coordinators in the HSA for different populations of patients • Determination of lead care coordinator for shared patients • Joint care plans and agreements for managing shared patients • Reciprocal referral protocols and methods of communication • Mechanisms for risk stratification and algorithms for determining which care managers will provide the care for which patient populations at what level of acuity Functional CHT: Interface with area health and human services agencies and ACOs The Blueprint Core CHT is a unique interdisciplinary team designed to support the general population. The Grantee shall help ensure coordination of care by supporting a Functional CHT consisting of key local health and human services agencies and ACOs, facilitating communication that reduces duplication of effort and enables the effective rendering of services. Key local providers include, but are not limited to, the local Home Health Agency, Designated Mental Health Agency, addictions treatment providers, Children’s Integrated Services (CIS) team, Enhanced Family Services (EFS) team, and ACOs.

Extended and Functional CHTs. The Grantee shall coordinate the operations of the Core CHT (the staff supported by the funding from the insurance payers) with Extended and Functional CHTs and shall develop collaborative relationships between the Core CHT and the Extended and Functional CHTs as outlined in the deliverables below. The Extended CHT activities include Medication Assisted Treatment (Spoke staff), Support and Services at Home (SASH), and insurer and ACO care managers, including the Vermont Chronic Care Initiative (VCCI). The Functional CHT includes key local health and human services providers. The Grantee in collaboration with extended and functional CHT members shall document and inform the State of the: • Respective roles of the Core CHT, Extended CHTs, and Functional CHT • Clear referral protocols and methods of communication between the Core CHT, Extended CHTs, and Functional CHT • Well-coordinated and non-duplicative services for participants Medication Assisted Treatment Medication Assisted Treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance abuse disorders. The Grantee shall plan, coordinate, and implement the hiring and placement of (or subcontracting for) nurse case management and licensed substance abuse and/or mental health clinicians with local physicians who prescribe buprenorphine in the Grantee’s health service area. The MAT staff may be hired by the Grantee or subcontracted by the Grantee, as approved by the State. The MAT staff will work as a team with prescribing physicians to monitor adherence to treatment, coordinate access to recovery supports, provide counseling and health promotion services, and provide comprehensive care management to patients receiving MAT. The MAT staff will document their activities in the practice’s clinical record. In addition, the Spoke staff, with assistance from the Project Manager, will document the Health Home quality measures, participate in program evaluation, and participate in relevant learning collaboratives as determined by the State. The State will provide funds for one licensed nurse care manager and one licensed substance abuse and/or mental health clinician for every 100 Medicaid beneficiaries receiving buprenorphine prescribed by HSA physicians. The State will provide financing for MAT staff through the CHT payments mechanism. There will be no patient co-payments or fees for these services to assure barrier-free access to these services for patients and providers. Support and Services at Home (SASH) Under the Multi-payer Advanced Primary Care Practice Demonstration project (MAPCP), Medicare supports the Support and Services at Home (SASH) program as part of the Blueprint CHTs. SASH teams supplement core CHT functions by providing intensive, multi-disciplinary, team-based, non-medical wellness and coordination of care support to Medicare beneficiaries in Vermont. The Designated Regional Housing Organizations (DRHOs) administer SASH locally and are responsible for hiring and supervising SASH staff. Insurer and ACO Care Managers Care managers for both public and private insurers and ACOs supplement core CHT functions by providing clinical case management and support services to individuals identified as currently or potentially at risk for poor health outcomes and thus high healthcare costs. For example, the Vermont Chronic Care Initiative (VCCI) focuses on the highest cost Medicaid beneficiaries to assist them in better managing their healthcare. The Grantee shall ensure that all CHTs coordinate with insurer care managers and shall implement policies and guidelines requiring: • Identification of care coordinators in the HSA for different populations of patients • Determination of lead care coordinator for shared patients • Joint care plans and agreements for managing shared patients • Reciprocal referral protocols and methods of communication • Mechanisms for risk stratification and algorithms for determining which care managers will provide the care for which patient populations at what level of acuity Functional CHT: Interface with area health and human services agencies and ACOs The Blueprint Core CHT is a unique interdisciplinary team designed to support the general population. The Grantee shall help ensure coordination of care by supporting a Functional CHT consisting of key local health and human services agencies and ACOs, facilitating communication that reduces duplication of effort and enables the effective rendering of services. Key local providers include, but are not limited to, the local Home Health Agency, Designated Mental Health Agency, addictions treatment providers, Children’s Integrated Services (CIS) team, Enhanced Family Services (EFS) team, and ACOs.

Extended and Functional CHTs. The Grantee shall coordinate the operations of the Core CHT (the staff supported by the funding from the insurance payers) with Extended and Functional CHTs and shall develop collaborative relationships between the Core CHT and the Extended and Functional CHTs as outlined outlines in the deliverables below. The Extended CHT activities include Medication Assisted Treatment (Spoke staff), Support and Services at Home (SASH), and insurer and ACO care managers, including the Vermont Chronic Care Initiative (VCCI). The Functional CHT includes key local health and human services providers. The Grantee in collaboration with extended and functional CHT members shall document and inform the State of the: • Respective roles of the Core CHT, Extended CHTs, and Functional CHT • Clear referral protocols and methods of communication between the Core CHT, Extended CHTs, and Functional CHT • Well-coordinated and non-duplicative services for participants Medication Assisted Treatment Medication Assisted Treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance abuse disorders. The Grantee shall plan, coordinate, and implement the hiring and placement of (or subcontracting for) nurse case management and licensed substance abuse and/or mental health clinicians with local physicians who prescribe buprenorphine in the Grantee’s health service area. The MAT staff may be hired by the Grantee or subcontracted by the Grantee, as approved by the State. The MAT staff will work as a team with prescribing physicians to monitor adherence to treatment, coordinate access to recovery supports, provide counseling and health promotion services, and provide comprehensive care management to patients receiving MAT. The MAT staff will document their activities in the practice’s clinical record. In addition, the Spoke staff, with assistance from the Project Manager, will document the Health Home quality measures, participate in program evaluation, and participate in relevant learning collaboratives as determined by the State. The State will provide funds for one licensed nurse care manager and one licensed substance abuse and/or mental health clinician for every 100 Medicaid beneficiaries receiving buprenorphine prescribed by HSA physicians. The State will provide financing for MAT staff through the CHT payments mechanism. There will be no patient co-payments or fees for these services to assure barrier-free access to these services for patients and providers. Support and Services at Home (SASH) Under the Multi-payer Advanced Primary Care Practice Demonstration project (MAPCP), Medicare supports the Support and Services at Home (SASH) program as part of the Blueprint CHTs. SASH teams supplement core CHT functions by providing intensive, multi-disciplinary, team-based, non-medical wellness and coordination of care support to Medicare beneficiaries in Vermont. The Designated Regional Housing Organizations (DRHOs) administer SASH locally and are responsible for hiring and supervising SASH staff. Insurer and ACO Care Managers Care managers for both public and private insurers and ACOs supplement core CHT functions by providing clinical case management and support services to individuals identified as currently or potentially at risk for poor health outcomes and thus high healthcare costs. For example, the Vermont Chronic Care Initiative (VCCI) focuses on the highest cost Medicaid beneficiaries to assist them in better managing their healthcare. • The Grantee shall ensure that all CHTs coordinate with insurer care managers and shall implement policies and guidelines requiring: Identification of care coordinators in the HSA for different populations of patients • Determination of lead care coordinator for shared patients • Joint care plans and agreements for managing shared patients • Reciprocal referral protocols and methods of communication • Mechanisms for risk stratification and algorithms for determining which care managers will provide the care for which patient populations at what level of acuity Functional CHT: Interface with area health and human services agencies and ACOs The Blueprint Core CHT is a unique interdisciplinary team designed to support the general population. The Grantee shall help ensure coordination of care by supporting a Functional CHT consisting of key local health and human services agencies and ACOs, facilitating communication that reduces duplication of effort and enables the effective rendering of services. Key local providers include, but are not limited to, the local Home Health Agency, Designated Mental Health Agency, addictions treatment providers, Children’s Integrated Services (CIS) team, Enhanced Family Services (EFS) team, and ACOs.

Extended and Functional CHTs. The Grantee shall coordinate the operations of the Core CHT (the staff supported by the funding from the insurance payers) with Extended and Functional CHTs and shall develop collaborative relationships between the Core CHT and the Extended and Functional CHTs as outlined in the deliverables below. The Extended CHT activities include Medication Assisted Treatment (Spoke staff), Support and Services at Home (SASH), and insurer and ACO care managers, including the Vermont Chronic Care Initiative (VCCI). The Functional CHT includes key local health and human services providers. The Grantee in collaboration with extended and functional CHT members shall document and inform the State of the: •  Respective roles of the Core CHT, Extended CHTs, and Functional CHT •  Clear referral protocols and methods of communication between the Core CHT, Extended CHTs, and Functional CHT •  Well-coordinated and non-duplicative services for participants Medication Assisted Treatment Medication Assisted Treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance abuse disorders. The Grantee shall plan, coordinate, and implement the hiring and placement of (or subcontracting for) nurse case management and licensed substance abuse and/or mental health clinicians with local physicians who prescribe buprenorphine in the Grantee’s health service area. The MAT staff may be hired by the Grantee or subcontracted by the Grantee, as approved by the State. The MAT staff will work as a team with prescribing physicians to monitor adherence to treatment, coordinate access to recovery supports, provide counseling and health promotion services, and provide comprehensive care management to patients receiving MAT. The MAT staff will document their activities in the practice’s clinical record. In addition, the Spoke staff, with assistance from the Project Manager, will document the Health Home quality measures, participate in program evaluation, and participate in relevant learning collaboratives as determined by the State. The State will provide funds for one licensed nurse care manager and one licensed substance abuse and/or mental health clinician for every 100 Medicaid beneficiaries receiving buprenorphine prescribed by HSA physicians. The State will provide financing for MAT staff through the CHT payments mechanism. There will be no patient co-payments or fees for these services to assure barrier-free access to these services for patients and providers. Support and Services at Home (SASH) Under the Multi-payer Advanced Primary Care Practice Demonstration project (MAPCP), Medicare supports the Support and Services at Home (SASH) program as part of the Blueprint CHTs. SASH teams supplement core CHT functions by providing intensive, multi-disciplinary, team-based, non-medical wellness and coordination of care support to Medicare beneficiaries in Vermont. The Designated Regional Housing Organizations (DRHOs) administer SASH locally and are responsible for hiring and supervising SASH staff. Insurer and ACO Care Managers Care managers for both public and private insurers and ACOs supplement core CHT functions by providing clinical case management and support services to individuals identified as currently or potentially at risk for poor health outcomes and thus high healthcare costs. For example, the Vermont Chronic Care Initiative (VCCI) focuses on the highest cost Medicaid beneficiaries to assist them in better managing their healthcare. The Grantee shall ensure that all CHTs coordinate with insurer care managers and shall implement policies and guidelines requiring: •  Identification of care coordinators in the HSA for different populations of patients  Determination of lead care coordinator for shared patients •  Joint care plans and agreements for managing shared patients •  Reciprocal referral protocols and methods of communication •  Mechanisms for risk stratification and algorithms for determining which care managers will provide the care for which patient populations at what level of acuity Functional CHT: Interface with area health and human services agencies and ACOs The Blueprint Core CHT is a unique interdisciplinary team designed to support the general population. The Grantee shall help ensure coordination of care by supporting a Functional CHT consisting of key local health and human services agencies and ACOs, facilitating communication that reduces duplication of effort and enables the effective rendering of services. Key local providers include, but are not limited to, the local Home Health Agency, Designated Mental Health Agency, addictions treatment providers, Children’s Integrated Services (CIS) team, Enhanced Family Services (EFS) team, and ACOs.

Extended and Functional CHTs. The Grantee shall coordinate the operations of the Core CHT (the staff supported by the funding from the insurance payers) with Extended and Functional CHTs and shall develop collaborative relationships between the Core CHT and the Extended and Functional CHTs as outlined in the deliverables below. The Extended CHT activities include Medication Assisted Treatment (Spoke staff), Support and Services at Home (SASH), and insurer and ACO care managers, including the Vermont Chronic Care Initiative (VCCI). The Functional CHT includes key local health and human services providers. The Grantee in collaboration with extended and functional CHT members shall document and inform the State of the: • Respective roles of the Core CHT, Extended CHTs, and Functional CHT • Clear referral protocols and methods of communication between the Core CHT, Extended CHTs, and Functional CHT • Well-coordinated and non-duplicative services for participants Medication Assisted Treatment Medication Assisted Treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance abuse disorders. The Grantee shall plan, coordinate, and implement the hiring and placement of (or subcontracting for) nurse case management and licensed substance abuse and/or mental health clinicians with local physicians who prescribe buprenorphine in the Grantee’s health service area. The MAT staff may be hired by the Grantee or subcontracted by the Grantee, as approved by the State. The MAT staff will work as a team with prescribing physicians to monitor adherence to treatment, coordinate access to recovery supports, provide counseling and health promotion services, and provide comprehensive care management to patients receiving MAT. The MAT staff will document their activities in the practice’s clinical record. In addition, the Spoke staff, with assistance from the Project Manager, will document the Health Home quality measures, participate in program evaluation, and participate in relevant learning collaboratives as determined by the State. The State will provide funds for one licensed nurse care manager and one licensed substance abuse and/or mental health clinician for every 100 Medicaid beneficiaries receiving buprenorphine prescribed by HSA physicians. The State will provide financing for MAT staff through the CHT payments mechanism. There will be no patient co-payments or fees for these services to assure barrier-free access to these services for patients and providers. Support and Services at Home (SASH) Under the Multi-payer Advanced Primary Care Practice Demonstration project (MAPCP), Medicare supports the Support and Services at Home (SASH) program as part of the Blueprint CHTs. SASH teams supplement core CHT functions by providing intensive, multi-disciplinary, team-based, non-medical wellness and coordination of care support to Medicare beneficiaries in Vermont. The Designated Regional Housing Organizations (DRHOs) administer SASH locally and are responsible for hiring and supervising SASH staff. Insurer and ACO Care Managers Care managers for both public and private insurers and ACOs supplement core CHT functions by providing clinical case management and support services to individuals identified as currently or potentially at risk for poor health outcomes and thus high healthcare costs. For example, the Vermont Chronic Care Initiative (VCCI) focuses on the highest cost Medicaid beneficiaries to assist them in better managing their healthcare. The Grantee shall ensure that all CHTs coordinate with insurer care managers and shall implement policies and guidelines requiring: Identification of care coordinators in the HSA for different populations of patients • Determination of lead care coordinator for shared patients • Joint care plans and agreements for managing shared patients • Reciprocal referral protocols and methods of communication • Mechanisms for risk stratification and algorithms for determining which care managers will provide the care for which patient populations at what level of acuity Functional CHT: Interface with area health and human services agencies and ACOs The Blueprint Core CHT is a unique interdisciplinary team designed to support the general population. The Grantee shall help ensure coordination of care by supporting a Functional CHT consisting of key local health and human services agencies and ACOs, facilitating communication that reduces duplication of effort and enables the effective rendering of services. Key local providers include, but are not limited to, the local Home Health Agency, Designated Mental Health Agency, addictions treatment providers, Children’s Integrated Services (CIS) team, Enhanced Family Services (EFS) team, and ACOs.

Extended and Functional CHTs. The Grantee shall coordinate the operations of the Core CHT (the staff supported by the funding from the insurance payers) with Extended and Functional CHTs and shall develop collaborative relationships between the Core CHT and the Extended and Functional CHTs as outlined in the deliverables below. The Extended CHT activities include Medication Assisted Treatment (Spoke staff), Support and Services at Home (SASH), and insurer and ACO care managers, including the Vermont Chronic Care Initiative (VCCI). The Functional CHT includes key local health and human services providers. The Grantee in collaboration with extended and functional CHT members shall document and inform the State of the: • Respective roles of the Core CHT, Extended CHTs, and Functional CHT • Clear referral protocols and methods of communication between the Core CHT, Extended CHTs, and Functional CHT • Well-coordinated and non-duplicative services for participants Medication Assisted Treatment Medication Assisted Treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance abuse disorders. The Grantee shall plan, coordinate, and implement the hiring and placement of (or subcontracting for) nurse case management and licensed substance abuse and/or mental health clinicians with local physicians who prescribe buprenorphine in the Grantee’s health service area. The MAT staff may be hired by the Grantee or subcontracted by the Grantee, as approved by the State. The MAT staff will work as a team with prescribing physicians to monitor adherence to treatment, coordinate access to recovery supports, provide counseling and health promotion services, and provide comprehensive care management to patients receiving MAT. The MAT staff will document their activities in the practice’s clinical record. In addition, the Spoke staff, with assistance from the Project Manager, will document the Health Home quality measures, participate in program evaluation, and participate in relevant learning collaboratives as determined by the State. The State will provide funds for one licensed nurse care manager and one licensed substance abuse and/or mental health clinician for every 100 Medicaid beneficiaries receiving buprenorphine prescribed by HSA physicians. The State will provide financing for MAT staff through the CHT payments mechanism. There will be no patient co-payments or fees for these services to assure barrier-free access to these services for patients and providers. Support and Services at Home (SASH) Under the Multi-payer Advanced Primary Care Practice Demonstration project (MAPCP), Medicare supports the Support and Services at Home (SASH) program as part of the Blueprint CHTs. SASH teams supplement core CHT functions by providing intensive, multi-disciplinary, team-based, non-medical wellness and coordination of care support to Medicare beneficiaries in Vermont. The Designated Regional Housing Organizations (DRHOs) administer SASH locally and are responsible for hiring and supervising SASH staff. Insurer and ACO Care Managers Care managers for both public and private insurers and ACOs supplement core CHT functions by providing clinical case management and support services to individuals identified as currently or potentially at risk for poor health outcomes and thus high healthcare costs. For example, the Vermont Chronic Care Initiative (VCCI) focuses on the highest cost Medicaid beneficiaries to assist them in better managing their healthcare. The Grantee shall ensure that all CHTs coordinate with insurer care managers and shall implement policies and guidelines requiring: • Identification of care coordinators in the HSA for different populations of patients • Determination of lead care coordinator for shared patients • Joint care plans and agreements for managing shared patients • Reciprocal referral protocols and methods of communication • Mechanisms for risk stratification and algorithms for determining which care managers will provide the care for which patient populations at what level of acuity Functional CHT: Interface with area health and human services agencies and ACOs The Blueprint Core CHT is a unique interdisciplinary team designed to support the general population. The Grantee shall help ensure coordination of care by supporting a Functional CHT consisting of key local health and human services agencies and ACOs, facilitating communication that reduces duplication of effort and enables the effective rendering of services. Key local providers include, but are not limited to, the local Home Health Agency, Designated Mental Health Agency, addictions treatment providers, Children’s Integrated Services (CIS) team, Enhanced Family Services (EFS) team, and ACOs.