OneCare Vermont

Vermont

OneCare Vermont is a statewide Accountable Care Organization that provides coordinated care for Vermont's Medicare, Medicaid and Commercial Exchange beneficiaries. OneCare adopts a holistic approach to care delivery, connecting patients with community-based services according to their unique physical health, mental health and social needs. Collaboration between providers is facilitated by shared use of the Care Navigator software, which allows all members of the care team (including the patient) to communicate updates and access the patient's care plan. This project is part of Robert Wood Johnson Foundation's Transforming Complex Care initiative. 

Partner Organizations

• Healthcare providers including: primary care providers, specialists, home healthcare agencies, hospice, skilled nursing facilities and Critical Access Hospitals
• Behavioral healthcare providers including: specialty hospitals and designated community mental health centers
• Social service providers including: agencies on aging and support and service providers
• University of Vermont Medical Center & Dartmouth-Hitchcock Medical Center (founders)

Target Population

Medicaid, Medicare, and commercially insured individuals identified based on recent inpatient hospitalizations, number of chronic conditions, number of specialty visits, gaps in care, visits to multiple pharmacies and diagnoses

Care Team

Nurses, social workers, health coaches, medical assistants, behavioral health and local social service providers

Timeframe

2012 - present 

Results/ Studies

Funding

University of Vermont Medical Center, Dartmouth-Hitchcock Medical Center

Resources

Program website

Profile by the Commonwealth Fund (2018)

Profile by the Center for Health Care Strategies, Inc. (2017)

Description of care coordination services