|Implemented in this survey?|
In May 2006, Vermont's state legislature passed the Health Care Affordability Act, which refocused the state?s Blueprint for Health program on prevention and management of chronic conditions. The new Blueprint Chronic Care Initiative was rolled out in several pilot sites in 2008, with an initial focus on a single condition, diabetes. Early data suggests the initiative is improving quality of care, health indicators, and engaging a broad range of stakeholders in chronic disease prevention.
New focus on prevention and management of chronic conditions
Vermont's Blueprint for Health, launched in 2003, is a statewide public-private partnership that has aimed to improve the health of Vermont residents while reforming the state's health care system. In May 2006, the Vermont state legislature passed the Health Care Affordability Act (H 861), which, in addition to creating Catamount Health, a program to cover uninsured Vermonters, also expanded and redefined the scope of the state's Blueprint for Health program. The 2006 Act refocuses the Blueprint's efforts on prevention and management of chronic conditions, such as asthma, diabetes and heart disease, as a means of cutting costs and improving care and outcomes across the state.
Blueprint Chronic Care Initiative implemented in two pilot projects
In 2008, two pilot projects, one at Northeast Vermont Medical Center and one at Fletcher Allen Medical Center, began implementing the Blueprint Chronic Care Initiative. Both centers formed Community Care Teams and committed to more than a dozen goals, including eliminating barriers to care; engaging communities in prevention and self-management of chronic conditions; coordinating care; and developing an integrated, routine evaluation plan. The Chronic Care Initiative has a strong emphasis on prevention activities and adoption of evidence-based practices across the spectrum.
Overall, the Blueprint has six "core competency" areas: public policy, community, self-management, information systems, provider support, and health systems. The Chronic Care Initiative engages all six of these areas. The initiative promotes early, coordinated screening for chronic conditions, better care, and promotion of patient self-management. In the first stage of the pilot, the Centers are focusing on a single chronic disease, diabetes. The pilot centers are identifying diabetic patients, entering (with permission) patient information into a statewide web-based registry, adopting protocols for evidence-based care, and promoting self-management activities. Meanwhile, grants to communities promote nutrition and physical activity programs, while the state is working to implement policies to promote healthier lifestyles, such as, for example, laws to encourage and facilitate biking and walking.
The initiative also includes plans to develop a statewide patient registry and tracking system, which will enable providers to track their patients' conditions and treatment; guide provider treatment decisions; enable group and individual-level monitoring; and provide a platform for e-prescribing. Ultimately, the initiative will move into new centers and communities, as well as new chronic disease and risk factor areas.
The overarching objectives of the Blueprint Chronic Care Initiative are to increase access to health care, improve quality of care, and contain costs, namely by changing the way clinical care is delivered, particularly care for chronic conditions.
The initiative has articulated several specific means toward these ends, namely:
The initiative has considered plans to waive co-pays for patients with chronic conditions or risk factors who seek care and take steps toward self-management. It also includes plans to implement a pay-for-performance component that will reward providers who meet certain standards for high-quality chronic disease care, including appointment reminders, follow-up care and in-home care.
Patients with chronic conditions or risk factors, providers
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
The Blueprint has been described as visionary, proactive, and holisitic for its focus on prevention, its systems view, and its emphasis on engaging the active participation of such a broad range of stakeholders. It is among the most comprehensive statewide programs designed to improve the health of and health care for people with chronic conditions to date in the US.
|Implemented in this survey?|
High prevalence of chronic conditions
A 2004 report commissioned from the RAND institute revealed that more than half of all Vermont residents with diabetes, high blood pressure, smoking habits, heart failure, asthma, depression or high cholesterol were not receiving the appropriate care. The costs of such a shortcoming in the health care system were high: chronic conditions account for 78% of health care spending in Vermont, 76% of hospital admissions, and 72% of all doctor visits. Contributing to the burden was the high cost of end-stage, reactive, often emergency care for patients with chronic conditions, as well as the high number of individuals with chronic conditions or diseases: more than half of all Vermont residents, and 88% of those over 65, have a chronic condition. The high health and economic costs associated with chronic disease prevalence drove the initiative to refocus the Blueprint's efforts on managing chronic diseases, an effort that calls for reforming the health care system into one that is no longer primarily responsive, but instead primarily proactive and collaborative.
Inspired by the Chronic Care Model
The Blueprint Chronic Care Initiative is based on the Chronic Care Model put forth in 1998 by Ed Wagner, director of the MacColl Institute for Healthcare Innovation in Seattle, Washington. The model identifies six areas crucial to the establishment of a system that provides high quality chronic disease care and management, namely, effective patient self-management; decision support for providers; streamlined, thorough health care delivery systems; a patient registry; organized health care systems; and community partnerships. The model promotes collaboration and quality improvement by involving a broad spectrum of stakeholders - individuals, communities, providers, and the public and private health care systems - in active steps to improve both health and health care systems. The initiative follows this model closely. It also has a strong focus on prevention in order to address the risk factors - such as obesity, poor nutrition, physical inactivity and tobacco use - that drive high rates of chronic disease.
The approach of the idea is described as:
Passage of the 2006 Health Care Affordability Act required consensus between the state's Republic governor and the democratically controlled legislative bodies, both of whom ultimately supported the initiative. Employer groups have resisted their financial responsibility for implementing Catamount Health, the other component of the Act that instituted the Chronic Care Initiative. Consumer support for the initiative has been inconsistent; while some communities report active participation in community-based prevention programming, others have been hampered by low and decreasing participation rates. Overall, support for various components of the Blueprint varies. Some health care delivery organizations, for instance, have engaged in provider training, registry adoption and care coordination efforts, but have had difficulty supporting community activities; one has decided to opt out of such programming. Provider support is high; in communities that have begun to adopt Blueprint components, 75 percent of all providers have agreed to participate. Health plans, which urged compromise in initial health reform efforts in Vermont, were more favorable toward the Chronic Care Initiative, which has, overall, enjoyed bipartisan support.
|Governor James Douglas||very supportive||strongly opposed|
|State legislature||very supportive||strongly opposed|
|State health department||very supportive||strongly opposed|
|Health care providers||very supportive||strongly opposed|
|Vermont health plans||very supportive||strongly opposed|
|Consumers||very supportive||strongly opposed|
|Private Sector or Industry|
|Employer groups||very supportive||strongly opposed|
|Governor James Douglas||very strong||none|
|State legislature||very strong||none|
|State health department||very strong||none|
|Health care providers||very strong||none|
|Vermont health plans||very strong||none|
|Private Sector or Industry|
|Employer groups||very strong||none|
In 2007, 59 training programs across the state trained providers in the Chronic Care model, information systems, prevention strategies, self-management promotion, and practice guidelines for managing diabetes, overweight, high cholesterol and high blood pressure. The patient registry system has been rolled out at three pilot centers in the state.
Self-management programs, which consist of Healthy Living Workshops based on a model developed by Stanford University researchers, have been implemented in 10 communities. The Workshops are led by peers who either have a chronic condition themselves or have experience caring for a person with a chronic condition. Ninety-one workshop leaders were trained across the state by the end of 2007, and 74 six-week workshops were held, led by 81 trained instructors with a total of 865 participants (581 of whom completed the full workshop course). Numbers were up from 2006, when workshops served a total of 300 participants.
The state has also begun to launch a hotline - Vermont 2-1-1 - which residents can call for information on local physical activity, exercise, nutrition and weight management programs. Several communities have, with state support, begun offering such prevention-oriented activities. Efforts vary widely in form: one community health center installed 45 "Take the Stairs" signs; another community developed and distributed a local walking map; another began offering free eight-week workout sessions and opened its local high school to early morning exercisers, before school hours; another began offering free yoga, Tai Chi and other courses at the local library.
The Blueprint has identified a strong infrastructure as critical to supporting ongoing monitoring and evaluation. A statewide health information exchange platform, which is still in the planning stages, will ultimately facilitate evaluation efforts. Pilot evaluation will take place within the pilot projects launched in 2008. The two pilot centers include patients covered by every payer in Vermont; the evaluation plan, at present, is to use claims data to compare outcomes for patients receiving care in the pilot centers to those for patients receiving routine care. A report released in early 2008 indicated that the planning for such an evaluation was still in the early stages.
A report on Recommendations for Evaluation and Performance Management of the Vermont Blueprint for Health, produced by the Delmarva Foundation, was released in February 2007. The report recommended that the Blueprint establish an Evaluation Workgroup and emphasize broad participation and consensus on the development of a strategic plan with embedded evaluation steps. The report also recommended that the original Blueprint deadline of statewide implementation by December 2008 be extended to give providers more time to learn about and adopt clinical measures for chronic conditions and to allow more time for the implementation of the Chronic disease registry. It also recommended, among other items, that health plans adopt, as part of the Blueprint's strategic plan, a standard pay for performance program for diabetes care in addition to pre- and post-training provider assessment. The report further recommended several sources of data - including the Department of Health, public and private plans, as well as data generated by Blueprint programs - that could be used in overall evaluations.
Evaluation efforts have generated data on one component of the initiative, the Healthy Living Workshops, which have a built-in evaluation component. Participants complete a pre- and post-participation assessment as well as six- and twelve-month follow-ups. Results are reported below.
In response to recommendations, the Blueprint has established an Evaluation Workgroup, which oversees the selection of measures and the collection of data; approves evaluation study designs; monitors the Blueprint's progress; and reports on progress to key stakeholders.
While planning for initiative-wide evaluations are underway, some data on progress by community partners is available. Pilot site Fletcher Allen Health Care, for one, has reported that it has identified 100% if its diabetic patients, trained all of its primary care providers in the patient registry, and developed a diabetic flow sheet, which is being implemented in its practices. Local initiatives have also reported improvements in care. In 2007, Gifford Medical Center increased the fraction of diabetes patients receiving LDL tests annually from 23 to over 33% and the fraction receiving HgA1c tests annually from 42.6 to 52.4%.
In this first stage, the Blueprint has set several goals for the improvement of diabetes care; the aim is for 90% of diabetic patients to have hgb A1c levels below 7; 70% to have an LDL below 100; 40% to have blood pressure below 130/80; and 90% to have their Hgb A1c checked twice a year. Northeast Vermont Medical Center has so far met or exceeded these goals, with the exception of patients with Hgb A1c levels below 7 (54%). Fletcher Allen is approaching but has not yet met these goals, according to 2007 data.
Data from the 2007 Healthy Living Workshops showed that participants made fewer visits to the doctor and emergency room over the course of the 12-month evaluation period. The evaluation also revealed, among other improvements, a 13% increase in the number of participants who felt that activities or non-medical approaches could help manage their condition; a 15% increase in the number who said fatigue didn't interfere with their activities; and a 14% increase in the number who said pain didn't interfere with their activities.
Vermont has plans to expand the Blueprint Chronic Care Initiative beyond the pilot sites and into additional disease areas beyond diabetes. The registry, which is currently being tested at three pilot sites, will be rolled out to additional communities and ultimately be accessible to providers across the state. Overall, the initiative has been projected to yield savings to the state totaling $550 million over the next ten years and slow the increase in health premiums in the state. In the shorter term, the state plans, and pilot sites have committed, to transition from a combination of state and payer financing for programs to complete payer financing within two years. Local editorials boards have predicted the initiative would struggle for lack of a consistent source of funding; the sustainability of the initiative's various components in the face of such a transition remains to be seen. In the meantime, however, national interest in the progress of Vermont's health reforms, including the Chronic Care Initiative, remains high.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
The Blueprint for Health, and its new Chronic Care Initiative, have attracted national attention. Blueprint leaders have been invited to speak at regional and national forums on governance and health care reform. The plan aims to fundamentally alter the nature of chronic disease management in the state of Vermont; if effective, it has the potential to dramatically reduce health care costs in the state as well.
Gifford Medical Center. "Quality Improvement Initative - Diabetes Care." Available at www.giffordmed.org/act53/pdf/2008/Diabetes_care.pdf.
Kaiser Family Foundation. "Vermont Health Care Reform Plan." Kaiser Commission on Key Facts. December 2007. Available at www.kff.org/uninsured/upload/7723.pdf.
Kent, Christina. Vermont Approves "Catamount Health," Chronic Care Initiative. State Health Notes Vol. 27, Issue 467, May 15, 2006. National Conference of State Legislatures. Available at www.ncsl.org/programs/health/shn/2006/sn467.htm.
Maxwell, James. "Comprehensive Health Care Reform in Vermont: A Conversation with Governor James Douglas." Health Affairs. October 16, 2007, w. 697. Available at http://content.healthaffairs.org/cgi/reprint/hlthaff.26.6.w697v1.
Vermont Department of Health. Vermont Blueprint for Health 2007 Annual Report. January 2008.
Vermont State Legislature. "Details on the Health Care Affordability Act." Available at www.leg.state.vt.us/HealthCare/Q&A_Details_on_Health_Care_Affordability_Act_