The Vermont Medical Homes Pilot

A National Council Fact Sheet

In 2002, Vermont's Medicaid program received a grant from the Center for Health Care Strategies, a national program of the Robert Wood Johnson Foundation, for a three-year demonstration project designed to improve the physical health needs of adults with serious and persistent mental illness. In three counties, "Care Partner" nurses were placed in community mental health centers, where they performed health assessments, made connections with primary care providers, and served as members of the community mental health centers' treatment teams. After much consideration, the community mental health centers and the nurses decided to begin the pilot by focusing primarily consumers who were diagnosed with Type II diabetes. The nurses also helped consumers implement nutrition and exercise programs as part of their recovery self-management plans.

After three years, preliminary data indicates that consumers who participated in the "Medical Home" project were able to significantly improve their health status and control health care costs:

• Prior to the implementation of the pilot, the 80 participants averaged 54 inpatient hospital days related to diabetes.
• In the 12 months following the pilot, the same group experienced no hospital days.¹  At the Howard Mental Health/Community Health Center of Burlington site, inpatient days for complications related to diabetes dropped off drastically.
• Planned care visits for diabetic consumers more than tripled, meaning consumers were keeping regular appointments designed to help them better control their diabetes.

"John": A Pilot Participant
"John," a 38-year-old participant, had numerous health problems when he entered the program: schizophrenia, hypertension, hypercholesterolemia, GERD (reflux disease), Type II diabetes, and a history of alcohol and drug abuse.²  He had a long history of being very "gung-ho" about his health but had difficulty following through. He quit smoking more times than anyone could remember and tried innumerable diets and exercise programs. John knew he had diabetes for quite some time before being willing to start taking oral medication (just shortly before becoming a participant). He rarely checked his blood sugar because he hated seeing his high readings. After one year in the pilot project, John had been smoke-free for six months, was walking 1-2 miles three to five days a week, checked his blood sugar daily, had a job, and had successfully avoided being hospitalized.

Program Recommendations
The program recommended the following components to support the infrastructure for care coordination and wellness promotion for consumers with chronic physical conditions:

• Shared decision making around medication
• Motivational interviewing regarding health behaviors
• Peer supports for nutrition and exercise
• Empowerment of families to support and advocate for wellness
• Community connections to foster natural supports and combat stigma
• Care Partner (nurses with ambulatory care and/or home health experience) co-location in community mental health programs
• Consultation-liaison between the nurse and the community mental health program Case Manager
• Continuum of care development — from total wraparound to information and referral (See National Council's "4 Quadrant" model)
• Connection with co-occurring disorders
• Trauma sensitivity

Vermont's Medicaid program currently reimburses community mental health centers for wellness and health risk assessments, counseling and/or heath risk factor reduction interventions and patient education services provided by a Registered Nurse Care Partner under the supervision of the consumers' attending psychiatrist.

The second phase of the Medical Home initiative is still in its early stages. Future evaluation of the program will focus on the return on investment for integrating medical and behavioral services within the community mental health system.

For more information, please contact Laura Galbreath at LauraG@thenationalcouncil.org.

¹ Mastal, Margaret F., et. al., Innovative Practices in Disability Care Coordination Organizations: Integrating Primary Care and Behavioral Health Clinical Systems, Lippincott Journal of Case Management (in press).
² Information on "John" and program recommendations provided by M. Elizabeth Reardon, M.P.H, Managed Care Director Office of Vermont Health Access.