Vt. Stat. Ann. tit. 18, § 703 - Health prevention; chronic care management under the health law

“Health prevention; chronic care management under the health law” 

The director of health must develop a model for integrating a system of health care for patients including a patient-centered medical home and a community health team and uniform payment for health services by health insurers, Medicaid, and Medicare.

The model for care coordination and management must include the following components:

• A process for identifying individuals with or at risk for chronic disease and the appropriate type and level of care management services.
• Evidence-based clinical practice guidelines.
• Models for the collaboration of health care professionals in providing care, including through a community health team.
• Education for patients on how to manage conditions or diseases, programs to modify a patient's behavior, and a method of ensuring compliance of the patient with the recommended behavioral change.
• Education for patients on health care decision-making, including education related to advance directives, palliative care, hospice care, and timely referrals to palliative and hospice care.
• Measurement and evaluation of the process and health outcomes of patients.
• A method for all health care professionals treating the same patient on a routine basis to report and share information about that patient.
• Requirements that participating health care professionals and providers have the capacity to implement health information technology.
• A financial model reforming primary care payment methods to promote health, prevent disease, and manage care in order to increase positive health outcomes and reduce costs over time.

The director of the Blueprint must provide technical assistance and training to health care professionals, health care providers, health insurers, and others participating in the Blueprint.