Helping all Vermonters access the best health services with an emphasis on prevention.

 Blueprint for Health

 About the Blueprint for Health . 

The Blueprint for Health (Blueprint) is Vermont’s state-led initiative charged with guiding a process that results in sustainable health care delivery reform. Originally codified in Vermont statute in 2006, then modified further in 2007, 2008, and finally in 2010 with Vermont Act 128 amending 18 V.S.A. Chapter 13 which defines Blueprint as a “program for integrating a system of health care for patients, improving the health of the overall population, and improving control over health care costs by promoting health maintenance, prevention, and care coordination and management.”

To that end, the Blueprint has worked with stakeholders in each of Vermont’s Health Service Areas to implement a new health services model.  The model includes:

  • Advanced primary care practices that are recognized as patient centered medical homes (PCMHs) by the National Committee for Quality Assurance (NCQA)
  • Multi-disciplinary core Community Health Teams (CHT) and additional specialized care coordinators, which support PCMHs and provide the general and target population access to multi-disciplinary health services
  • Evidence-based self-management programs to help citizens adopt healthier lifestyles and engage in preventive health services
  • Multi-insurer payment reforms that fund PCMH transformation and community health teams
  • Implementation of health information technology (HIT) to support health information exchange, guideline-based care, population management, and comparative evaluation
  • Multi-faceted evaluation system to determine the impacts of health care reform initiatives
  • A Learning Health System that helps practices and community health teams plan and implement PCMH operations, and supports ongoing quality improvement and innovation

In 2013, the Blueprint continued to grow and strengthen the underlying model in all geographic regions or Health Service Areas (HSAs) in the state.  A few highlights include:

  • NCQA recognition of 17 new practices serving an additional 91,370 patients
  • Blueprint recognition of the first naturopathic practice as an advanced primary care practice
  • Cumulative recognition of 121 PCMH practices serving a total of 514,385 Vermonters
  • Expansion to 120 CHT staff statewide
  • Statewide SASH coverage with 36.5 SASH teams serving high risk Medicare beneficiaries
  • New model of care for Opioid Addiction Treatment called Hub and Spoke implemented statewide with 5 regional addiction treatment centers (Hubs) and 30 Spoke staff (nurses and clinicians) deployed to buprenorphine prescribing practices (Spokes)

  2014 Blueprint Semi-Annual Conference Materials . 

Agenda

Abstracts

2014 Semi-Annual Blueprint Conference

Lake Morey Resort

Fairlee, Vermont

Monday, October 20, 2014

Homes, Teams, and Networks: A Foundation for Vermont’s Health Reforms

Keynote address presented by Craig Jones, MD, Director of the Vermont Blueprint for Health

SESSION I – 10:00am-11:00am

Improving Care Coordination in Pediatric Primary Care, Lessons Learned

Pediatric medical homes across the state have embarked on a journey to improve care coordination within their practice and in collaboration with community based organizations. Learn how a multi-disciplinary team from one of the practices has made a difference in their patients’ lives. Presented by Miriam Sheehey, RN, Beth Ann Maier, MD, Marinell Newton, LICSW & Kristy Trask, RN.

 

Raising The Bar: NCQA Patient Centered Medical Home 2014 Standards

NCQA recently released the NCQA PCMH 2014 Standards. Come find out what is new for primary care practices and community health teams within these new standards. Presented by Julianne Krulewitz, PhD.

 

Panel What? The Ins and Outs of Improving Patient Care through Panel Management

How do you identify a panel of patients using an electronic health record (EHR), ensure the list is accurate, and outreach to patients to improve patient care? Learn how one practice and their community health team staff does it effectively across several services and conditions. Presented by Don Grabowski.

 

Recognizing the Impact of Traumatic Events in Primary Care Patients

The groundbreaking study on Adverse Childhood Experiences (ACES) conducted by Kaiser Permanente in California found that experiences of abuse, neglect, and traumatic events in childhood were correlated with higher rates of chronic disease, substance abuse, and depression in adults. Somewhat less expected was the finding that simply asking “what happened to you” is a helpful healing strategy. This workshop will overview how primary care can screen for ACES and discuss pathways to additional support for people with history of trauma. Presented by Margaret Joyal, Director OUT-Pt MH Services WCMHS & Kathleen Hentcy, DMH.

 

Profiling Primary Care Practice

The Blueprint provides profiles to participating practices with demographic and health status information for the patient population, expenditures by major categories, health care utilization and effective and preventative care measures. The reports allow comparison between practices and their area peers and to statewide trends. The newest profiles, about to be released, will include commercial, Medicaid and Medicare data; Vermont is one of very few states able to provide this kind of reporting across health insurers. The profiles can be used for practice-level QI, health area planning and care coordination and to evaluate the impact of patient-centered medical homes and community health teams statewide. During the coming year the profiles will be released on six month cycles making the data even more timely and useful. This is a unique opportunity to interact with the leader of the analytics team that creates the profiles. Presented by Karl Finison, MA Director of Analytic Development, Onpoint Health Data.

 

SESSION II – 11:10am-12:10pm

Community-Wide Narcotics Protocol

Controlled Substance Management Agreement (Form)

Pain Informed Consent (Form)

In the face of growing community concern about prescription drug abuse, addiction, and diversion of prescription opiates Rutland area providers came together to create common protocols for treatment of chronic pain including shared protocols for prescribing practices, patient consent, and sharing of information between providers. The group has developed a public education and awareness campaign to assist with initial roll-out. The director of RRMC Psychiatric Services will present how the Rutland community organized the common protocols and discuss adapting their approach to other communities. Presented by Jeff McKee, RRMC Director of Psychiatric Services.

 

Health System Alignment: Blueprint and ACOs

Come learn how the Accountable Care Organization (ACO) standards align with the Patient Centered Medical Home recognition. Gather ideas on how you can support the ACO goals in your health service areas. Presented by Miriam Sheehey, RN.

 

“Who’s on First?” Interagency Care Coordination: The SASH Approach

Support and Services at Home (SASH) has organized a consistent approach to interagency agreements for care coordination on behalf of individuals with complex needs. Area Agencies on Aging, Home Health, Designated Mental Health and Substance Abuse Agencies, local hospitals, and housing providers all collaborate via a series of MOU’s and structured meetings. Presented by Amy Perez, State-Wide Coordinator for Southern and Central VT, Kenneth Russell, Central Valley SASH, & Christine Hazzard, Brattleboro, SASH.

 

Preventing Suicide by People Seen in Primary Care

Nationally, 50% of the people who died by suicide were seen by a primary care provider in the month prior to their death. Suicide risk is a set of identifiable conditions that are responsive to screening and intervention. The Fletcher Allen Community Health Team will highlight the process to systematically identify risk, screen for suicide, and pathways for follow-up and care. Also discussed will be describing evidence-based approaches for treating suicidality that can be implemented in a wide variety of health and mental health treatment settings. Presented by Pam Farnham, RN, Diane Collias, LICSW & Corey Gould, LPMA.

 

Mapping Community Networks

Last year the Blueprint commissioned the first formal analysis of the growing networks of health, human services and community supports in each Health Services Area. The resulting maps show the depth of connection and diversity of partners and raise new questions about how we can best work together to serve clients and patients in local communities. The second round of this study launches at the beginning of November. If you haven't heard about this research before, this is a great introduction -- if you have, come learn what's new for this year! Presented by Maurine Gilbert.

 

SESSION III – 1:00pm-2:00 pm

A Roadmap for Diabetes Care: Coordination Between Primary and Specialty Care

We all need to work together to improve the health of our patients. The diabetes roadmap is the first of several efforts to coordinate care delivery between primary care and specialty medicine. Fletcher Allen Health Care will discuss our process, the product and our outcomes. Presented by Dr. Jennifer Gilwee & Dr. Joel Schnure.

 

Medicaid EHR Incentive Program Audits

The auditor for The Vermont Medicaid EHR Incentive Program, will present an overview of the program’s audit and appeals process, as well as provide tips on how to prepare for an audit. Presented by Heather Kendall, PhD.

 

Emergency Department Utilization: A Tale of Two Health Service Areas

Two HSAs share their strategies to reduce avoidable emergency department use by assisting patients in enrolling in a patient center medical homes. Presented by Elise McKenna, RN, MPH, MSEd & Claudia Courcelle, RN, BSN, MSA.

 

Targeting Support & Services to Families with Young Children

Research shows that supporting pregnant women and young children can strengthen families and reduce adverse outcomes including health. In 2012, the Vermont Department of Health implemented an evidence-based home visiting model called the Nurse Partnership to support Medicaid eligible first time moms and their children. Discussed will be the key components of nurse home visiting and the many opportunities to coordinate home visiting and outreach to families with the Blueprint pediatric, family medicine, and community health team staff. Presented by Dr. Breena Holmes & Becca Rainville, NFP.

 

Profiling Primary Care Practice

The Blueprint provides profiles to participating practices with demographic and health status information for the patient population, expenditures by major categories, health care utilization and effective and preventative care measures. The reports allow comparison between practices and their area peers and to statewide trends. The newest profiles, about to be released, will include commercial, Medicaid and Medicare data; Vermont is one of very few states able to provide this kind of reporting across health insurers. The profiles can be used for practice-level QI, health area planning and care coordination and to evaluate the impact of patient-centered medical homes and community health teams statewide. During the coming year the profiles will be released on six month cycles making the data even more timely and useful. This is a unique opportunity to interact with the leader of the analytics team that creates the profiles. Presented by Karl Finison, MA Director of Analytic Development, Onpoint Health Data.

 

SESSION IV – 2:10pm-3:10 pm

Co-Managing Care: Primary Care and Specialty Mental Health / Addictions Treatment

Co-Management Agreement (Form)

Co-Management Fax (Form)

Diabetes Co-Management Agreement (Form)

Although the benefits of integrating health and mental health care are widely recognized and patients are often seen in both settings, formal arrangements between primary care and mental health providers are not common. Representatives from the Bennington and St. Albans communities will share example referral and co-managements agreements, discuss the development process they used and share insights into addressing implementation challenges. Presented by Jennifer Fels, Kim Turner, Julie Parker & Deb Green, RN.

 

Vermont Information Technology Leaders (VITL) Present VITLAccess

Access to patient clinical data at the point of care is at the core of improving health care outcomes for Vermont citizens. This session provides an overview of VITLAccess, VITL's new statewide provider portal that assembles patient information received from health care organizations across the state and, with patient consent, provides access to this information through a single secure portal. The statewide VITLAccess roll-out plan and the role of Blueprint Community Health teams in that roll-out plan will also be shared during this session. Presented by Judith Franz & Rob Gibson, CAHIMS.

 

Aligning ACO and Blueprint Infrastructure

Springfield Blueprint Presentation

MGP Quality Improvement

In the rapidly evolving ACO landscape local leaders are being asked to develop resources for complex care management and quality improvement. The Blueprint platform of patient-centered medical home, community health teams, and evaluation & measurement reporting seems ideal to support the developing ACOs. Aligning the Blueprint and ACO work, enhancing the existing infrastructure, and consolidating disparate initiatives takes purposeful and focused leadership. Presented by Patrick Clark & Josh Dufresne.

 

Screening, Brief Intervention and Referral to Treatment SBIRT

This evidence-based approach to initial engagement in changing risky substance abuse behavior is being implemented in a variety of Vermont primary care and treatment settings through one-time grants. The techniques are easily generalizable and useful for Community Health Teams and Patient-Centered Medical Homes. The presenters will overview the SBIRT model and describe how it is being implemented in primary care settings. Presented by Naya Pyskacek, LICSW, LADC.

 

Mapping Community Networks

Last year the Blueprint commissioned the first formal analysis of the growing networks of health, human services and community supports in each Health Services Area. The resulting maps show the depth of connection and diversity of partners and raise new questions about how we can best work together to serve clients and patients in local communities. The second round of this study launches at the beginning of November. If you haven't heard about this research before, this is a great introduction -- if you have, come learn what's new for this year! Presented by Maurine Gilbert.

 

  Blueprint Notifications and Staff Contact Information .

Contact Information

  Blueprint Annual Reports . 

2013 Annual Report (Jan. 2014) 

2012 Annual Report (Feb. 2013) 

2011 Annual Report  (Jan. 2012)

2010 Annual Report  (Jan. 2011)

2009 Annual Report (Jan. 2010)

  Blueprint Annual Reports Supporting Documents . 

2012 Annual Report Supporting Documents

State of VT: Concept for Medicaid Health Home Program

Planning Guidance to Expand Blueprint Community Health Teams with "Spoke Staffing" for Treatment of Opioid Dependence

Regional Comprehensive Addictions Treatment Centers RFP

2011 Annual Report Supporting Documents

VCHIP - Qualitative Evaluation of Provider and Practice Staff & Blueprint-Related Team Members and

Patient Perceptions Related to Adoption of the Blueprint for Health in Two Vermont Communities (7-15-11)

 

  2014 Blueprint Annual Conference Meeting Materials . Now available!

Vermont Blueprint for Health Annual Conference 2014: Empowering People - Morning Sessions

Vermont Blueprint for Health Annual Conference 2014: Empowering People - Afternoon Sessions

 

Choosing Wisely: Culture, Strategy and Transformation (PPTX 5 MB)
John Santa, MD, MPH
Medical Director,
Consumer Reports Health

 

Kevin Grumbach, MD
Professor and Chair of the Department of Family and Community Medicine
University of California, San Francisco
 
 

Vermont Blueprint for Health (PDF 1 MB)
Craig Jones, MD
Director
Vermont Blueprint for Health

 

The Swiss Healthcare System: Integration of Public Health and Prevention Programs (PDF 1 MB)
Ursula Koch, MSc, MPH, MS
Head of division of the National Prevention Programs at the Federal Office of Public Health
Switzerland

 

Blueprint Networks Analysis: A Study of the Secret Sauce (PDF 2 MB)
Maurine Gilbert
Research Specialist
University of Vermont - VCHIP

 

A Deep Dive Into Supports and Services at Home (SASH) (PDF 2.2 MB)
Molly Dugan, BS, MPA, MD
Stefani Hartsfield
Lise MacDonald, MEd

 

Kate McIntosh, MD
Rainbow Pediatrics

 

  Blueprint Health Service Area Semi-Annual Report . 

HSA Semi-Annual Report (Due April 30, 2014)

  2013 Blueprint Annual Conference Meeting Materials . 

2013 Conference Brochure 

Vermont Blueprint for Health Annual Conference 2013: Health System Innovation, Practice and Policy: The Long View, Part 1 of 4. 04/17/2013

Vermont Blueprint for Health Annual Conference 2013: Health System Innovation, Practice and Policy: The Long View, Part 2 of 4. 04/17/2013

Vermont Blueprint for Health Annual Conference 2013: Health System Innovation, Practice and Policy: The Long View, Part 3 of 4. 04/17/2013

Vermont Blueprint for Health Annual Conference 2013: Health System Innovation, Practice and Policy: The Long View, Part 4 of 4. 04/17/2013

 

  Blueprint Advisory Groups - Meeting Schedules, Minutes, Agendas . 

Blueprint Executive Committee

Blueprint Expansion Design and Evaluation Work Group

Blueprint Payment Implementation Work Group

Blueprint Mental Health and Substance Abuse Advisory Committee

 

  Blueprint Presentations: 

Data Quality Webinar

 

  Hub and Spoke Documents .

Planning Guidance to Expand Blueprint Community Health Teams with "Spoke Staffing" for Treatment of Opioid Dependence

 

  Blueprint Implementation Materials .

Bulletin 10-19-Vermont Blueprint for Health Rules (Adopted 3/5/11)

Blueprint Manual (Nov. 2010)

 

  2012 Grant Reporting Forms .

 

CHT Plan Guidance

HSA Report Schedule

Total Unique Patients Template

CHT Staffing Work Book

Financial Report Form

HIT Log

HSA Report Template

Practice Demographics - Staffing- NCQA Schedule Sheet

 

  Tobacco Cessation .

Tobacco Cessation Workshops

Thinking about quitting smoking??  Well Vermont has Tobacco Cessation Workshops around the state to help you kick that habit. If you'd like to get help in person, there are local Vermont Quit Network group coaches available in communities throughout Vermont.

Just like the phone coaches, they'll help you set your quit date and get ready to quit. And, they also offer free nicotine replacement - gum, patches or lozenges - when you use the service, and it's shipped directly to you home. Once you've quit, they'll help you with advice and support. Remember, quitting is tough, but it's easier when there's someone to help you. To find a quit group in your area please check the schedule below and for more information go to http://802quits.org/in-person-quit-help/

Tobacco Cessation Group Workshops Schedule

 

  Healthier Living Workshops .

Which Healthier Living Workshop is for You?

WRAP Implementation Guide (May 2013) 

Chronic Pain Overview

Diabetes Overview

Chronic Disease Self-Management Program

Healthier Living Workshop Training Refreshers 2012  (2/15/12)

Freshstart - Facilitators Training March 16th Gifford Medical Center (2-15-12)

2012 Project Managers Meeting Schedule

Healthier Living Workshop Evaluation (November 2011)

2013 Healthier Living Workshop Calendar (February 2013)

Attendance Sheet (1-26-2012)

Project Managers List (1-2013)

Project Managers - Map (Nov-11)

HLW Regional Coordinators List (1-9-2013)

Regional Coordinator Map (Jan. 2013)

Steps for Healthier Living Workshop Paper Work. (April 2011)

Combined Schedule Workshop (April 2011)

Healthier Living Workshop Final Evaluation Form (April 2011)

Healthier Living Workshop Evaluation Baseline Form (April 2011)

Template Letter to Healthcare Provider (April 2011)