New England Consortium:
Vermont Independence Project

Project Overview

General Approach: The Vermont Independence Project (VIP) is an initiative to improve the service delivery system for elderly and/or disabled Vermonters who are or soon will be dual eligibles. In 1996, the Vermont legislature passed Act 160, a long-term care reform law intended to "shift the balance" from institutional care to home and community-based long-term care services. Through Act 160, ten community-based long-term care coalitions have formed around the state; these coalitions will form the foundation for an integrated delivery system for dually eligible beneficiaries.

In October 1999 Vermont implemented a Medicaid primary care case management program called PC Plus through an 1115 waiver amendment. Dual eligibles are not eligible to participate in the 1115 waiver, but Vermont, in the future, may give them the option of joining and/or remaining in PC Plus through state plan amendment authority. The goal is to allow dually eligible Vermonters to be in PC Plus and to have access to a "Care Partner". The Care Partner will interface with the PCP and the beneficiary and coordinate access to long-term care, social services and disease management services depending upon the beneficiary's assessed needs.

Waiver(s): N/A

Current Status

7/2000: VIP staff solicited bids from the 10 long-term care coalitions in Vermont to develop Care Partner Pilot sites
9/2000: VIP received and reviewed bids from 5 of the 10 long-term care coalitions in Vermont
9/2000: VIP selected Franklin Grand Isle Advocates for Long Term Care and the Windham County Long Term Care Coalition as the 2 Care Partner Sites for this project
9/2000-current: Plan for and plan while implementing Care Partner Pilot Sites. Each of the Long Term Care Coalitions has subcontracted the project to the Local Area Agency on Aging.
4/2001 to current: 7 Local Area Agency on Aging (AAA) Case Managers are dividing time in this project between hours at a participating Primary Care Provider's office and their AAA office. This program will test the impact of having a case manager physically co-located at a PCP office & enhanced care planning for low-income elderly and disabled Vermonters. All Medicare & Medicaid services are reimbursed using the existing fee-for-service system
** Participating primary care providers have volunteered to work in this project, are not be reimbursed for their participation, and have viewed the assistance of a physically collocated case manager/care partner an invaluable asset to their office.

Target Population:

Level 1 Clients: are dually eligible (eligible for both Medicare and Medicaid), have a complex care need (social service and/or medical need), and are referred by the participating PCP.
Level 2 Clients: have Medicare, are eligible for a Medicaid program (i.e. QMB, SLMB, VHAP pharmacy, VSCRIPT or Healthy Vermonters program), have a complex care need (social service and/or medical needs), and are referred by the participating PCP.

The pilot sites are currently planned to run from 3/01 - 7/03.

Case Managers from Champlain Valley Agency on Aging (CVAA) and the Council on Aging for Southeastern Vermont (COASEV) Windham are serving as "Care Partners" in 3 Vermont counties: Franklin, Grand Isle and Windham.

7 Care Partners are working part time in 7 PCP offices.

Goals of the Care Partner pilot sites:

1. Establish and/or enhance a relationship between the Care Partner and PCPs.
2. Work with clients on identifying their medical and social service needs.
3. Work with PCPs and clients on development of a care plan to address # 2 &
   • Decrease inappropriate use of Emergency services and hospitalizations
   • Increase coordination of home & community based long-term care
   • Increase medical coordination of client's prescription drugs.
4. Work with VIP staff on data collection and evaluation.
5. Work with VIP staff on sustainability options for the program.

Some of the expected outcomes from the Care Partner Pilot sites include:

1. Increased job satisfaction for both the Care Partner and the PCP.
2. Increased care coordination.
3. Decreases in the following utilization: ER, IP hospital, SNF, & RX with data to show these outcomes.
4. Program sustainability plan developed by staff from the: state, pilot sites and consumers.

Reports created to date in this project: (available upon request)

• Vermont 1996-1999, Dual Eligible, Medicare and Medicaid, Number of Beneficiaries & Claims Utilization Figures for 1996-1999, Charts and Tables, Adults Age 18 and older.
• Vermont Independence Project's Care Partner Pilot Site Program, Year One in Review 3/01-2/02, This report includes primary care and care partner survey summaries.

Reports due by early 2003

• Tri State, Maine, New Hampshire and Vermont, Linked Medicare and Medicaid data analysis for 1999, Charts and Tables, Adults Age 18 and older.
• Referral information analysis and functional assessment analysis of participants in the Care Partner Project.
• Second round summary report of primary care and care partner surveys for this project.

Next Steps

• Training for Care Partners will continue through the duration of the program
• VIP will contract with local long-term care coalition agencies (local Area Agencies on Aging) to run the Care Partner Program from 1/1/01 to 7/30/03.
• Link the linked Medicare/Medicaid data with functional status information for Care Partner clients to provide a database with claims data and functional status information (ADL/IADL)

Contact Information

Brendan Hogan
Managed Care Administrator
Office of Vermont Health Access
103 S. Main Street
Waterbury, VT 05671
Phone: (802) 241-3989
Fax: (802) 241-2897
Email: brendanh@path.state.vt.us
Website: http://www.ahs.state.vt.us