Common use of Extended and Functional CHTs Clause in Contracts

Extended and Functional CHTs. The Grantee shall coordinate the operations of the Core CHT (the staff supported by the funding from the insurance payer) with Extended and Functional CHTs, and shall develop strong collaborative relationships between the Core CHT and the Extended and Functional CHTs. The Extended CHT activities include Medication Assisted Treatment (Spoke staff), Support and Services at Home (SASH), and the Vermont Chronic Care Initiative (VCCI). The Functional CHT includes key local health and human services providers. The Grantee in collaboration with extended and functional CHT members shall document: • Respective roles of the Core CHT, Extended CHTs, and Functional CHT • Clear referral protocols and methods of communication between the Core CHT, Extended CHTs, and Functional CHT • Well-coordinated and non-duplicative services for participants Medication Assisted Treatment The State is collaborating with community providers to create a coordinated, systematic response to the complex issues of opioid and other addictions in Vermont. Medication Assisted Treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance abuse disorders. The Grantee shall plan, coordinate and implement the hiring and placement of (or subcontracting for) nurse case management and licensed substance abuse and/or mental health clinicians with local physicians who prescribe buprenorphine in the Grantee’s health service area. The MAT staff will work as a team with prescribing physicians to monitor adherence to treatment, coordinate access to recovery supports, provide counseling and health promotion services, and provide comprehensive care management to patients receiving MAT. The MAT staff will document their activities in the practice’s clinical record and within DocSite. In addition, the Spoke staff, with assistance from the Project Manager, will document the Health Home quality measures, participate in program evaluation, and participate in learning collaboratives. The State will provide funds for one licensed nurse care manager and one licensed substance abuse and/or mental health clinician for every 100 buprenorphine patients served by HSA physicians. The State will provide financing for MAT staff through the CHT payments mechanism, administered in cooperation with their contracted fiscal agent. There will be no patient co-payments or fees for these services to assure barrier-free access to these services for patients and providers. Support and Services at Home (SASH) Under the Multi-payer Advanced Primary Care Practice Demonstration Project, Medicare is supporting the development of the Support and Services at Home (SASH) program as part of the Blueprint CHTs. SASH teams are intended to supplement core CHT functions by providing intensive, multi-disciplinary, team-based non-medical wellness and coordination of care support to Medicare beneficiaries in Vermont who are at risk for poor health outcomes and high health care costs. The Designated Regional Housing Organization will administer SASH locally and will be responsible for hiring and supervising SASH staff. The Vermont Chronic Care Initiative (VCCI) The VCCI provides clinical case management and support services to the most high-cost Medicaid beneficiaries in order to better manage their health care. The Vermont Chronic Care Coordinators are intended to supplement core CHT functions by providing intensive case management to the most high-cost Medicaid beneficiaries. Functional CHT: Interface with area health and human services providers The Blueprint Core CHT is a unique interdisciplinary team designed to support the general population served by participating primary care practices. The Grantee shall help to ensure coordination of care by supporting a Functional CHT consisting of key local health and human services providers and to ensure that services are efficiently rendered and not duplicated. Key local providers include but are not limited to the local Home Health Agency, Designated Mental Health Agency, addictions treatment providers, Children’s Integrated Services (CIS) team, and Enhanced Family Services (EFS) team. Grant Deliverables

Extended and Functional CHTs. The Grantee shall coordinate the operations of the Core CHT (the staff supported by the funding from the insurance payer) with Extended and Functional CHTs, and shall develop strong collaborative relationships between the Core CHT and the Extended and Functional CHTs. The Extended CHT activities include Medication Assisted Treatment (Spoke staff), Support and Services at Home (SASH), and the Vermont Chronic Care Initiative (VCCI). The Functional CHT includes key local health and human services providers. The Grantee in collaboration with extended and functional CHT members shall document: • Respective roles of the Core CHT, Extended CHTs, and Functional CHT • Clear referral protocols and methods of communication between the Core CHT, Extended CHTs, and Functional CHT • Well-coordinated and non-duplicative services for participants Medication Assisted Treatment The State is collaborating with community providers to create a coordinated, systematic response to the complex issues of opioid and other addictions in Vermont. Medication Assisted Treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance abuse disorders. The Grantee shall plan, coordinate and implement the hiring and placement of (or subcontracting for) nurse case management and licensed substance abuse and/or mental health clinicians with local physicians who prescribe buprenorphine in the Grantee’s health service area. The MAT staff will work as a team with prescribing physicians to monitor adherence to treatment, coordinate access to recovery supports, provide counseling and health promotion services, and provide comprehensive care management to patients receiving MAT. The MAT staff will document their activities in the practice’s clinical record and within DocSiteDocSite when DocSite becomes available for this purpose. In addition, the Spoke staff, with assistance from the Project Manager, will document the Health Home quality measures, participate in program evaluation, and participate in learning collaboratives. The State will provide funds for one licensed nurse care manager and one licensed substance abuse and/or mental health clinician for every 100 buprenorphine patients served by HSA physicians. The State will provide financing for MAT staff through the CHT payments mechanism, administered in cooperation with their contracted fiscal agent. There will be no patient co-payments or fees for these services to assure barrier-free access to these services for patients and providers. Support and Services at Home (SASH) Under the Multi-payer Advanced Primary Care Practice Demonstration Project, Medicare is supporting the development of the Support and Services at Home (SASH) program as part of the Blueprint CHTs. SASH teams are intended to supplement core CHT functions by providing intensive, multi-disciplinary, team-based non-medical wellness and coordination of care support to Medicare beneficiaries in Vermont who are at risk for poor health outcomes and high health care costs. The Designated Regional Housing Organization will administer SASH locally and will be responsible for hiring and supervising SASH staff. The Vermont Chronic Care Initiative (VCCI) The VCCI provides clinical case management and support services to the most high-cost Medicaid beneficiaries in order to better manage their health care. The Vermont Chronic Care Coordinators are intended to supplement core CHT functions by providing intensive case management to the most high-cost Medicaid beneficiaries. Functional CHT: Interface with area health and human services providers The Blueprint Core CHT is a unique interdisciplinary team designed to support the general population served by participating primary care practices. The Grantee shall help to ensure coordination of care by supporting a Functional CHT consisting of key local health and human services providers and to ensure that services are efficiently rendered and not duplicated. Key local providers include but are not limited to the local Home Health Agency, Designated Mental Health Agency, addictions treatment providers, Children’s Integrated Services (CIS) team, and Enhanced Family Services (EFS) team. Grant Deliverables

Extended and Functional CHTs. The Grantee shall coordinate the operations of the Core CHT (the staff supported by the funding from the insurance payer) with Extended and Functional CHTs, and shall develop strong collaborative relationships between the Core CHT and the Extended and Functional CHTs. The Extended CHT activities include Medication Assisted Treatment (Spoke staff), Support and Services at Home (SASH), and the Vermont Chronic Care Initiative (VCCI). The Functional CHT includes key local health and human services providers. The Grantee in collaboration with extended and functional CHT members shall document: • Respective roles of the Core CHT, Extended CHTs, and Functional CHT • Clear referral protocols and methods of communication between the Core CHT, Extended CHTs, and Functional CHT • Well-coordinated and non-duplicative services for participants Medication Assisted Treatment The State is collaborating with community providers to create a coordinated, systematic response to the complex issues of opioid and other addictions in Vermont. Medication Assisted Treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance abuse disorders. The Grantee shall plan, coordinate and implement the hiring and placement of (or subcontracting for) nurse case management and licensed substance abuse and/or mental health clinicians with local physicians who prescribe buprenorphine in the Grantee’s health service area. The MAT staff will work as a team with prescribing physicians to monitor adherence to treatment, coordinate access to recovery supports, provide counseling and health promotion services, and provide comprehensive care management to patients receiving MAT. The MAT staff will document their activities in the practice’s clinical record and within DocSite. In addition, the Spoke staff, with assistance from the Project Manager, will document the Health Home quality measures, participate in program evaluation, and participate in learning collaboratives. The State will provide funds for one licensed nurse care manager and one licensed substance abuse and/or mental health clinician for every 100 buprenorphine patients served by HSA physicians. The State will provide financing for MAT staff through the CHT payments mechanism, administered in cooperation with their contracted fiscal agent. There will be no patient co-payments or fees for these services to assure barrier-free access to these services for patients and providers. Support and Services at Home (SASH) Under the Multi-payer Advanced Primary Care Practice Demonstration Project, Medicare is supporting the development of the Support and Services at Home (SASH) program as part of the Blueprint CHTs. SASH teams are intended to supplement core CHT functions by providing intensive, multi-disciplinary, team-based non-medical wellness and coordination of care support to Medicare beneficiaries in Vermont who are at risk for poor health outcomes and high health care costs. The Designated Regional Housing Organization will administer SASH locally and will be responsible for hiring and supervising SASH staff. The Vermont Chronic Care Initiative (VCCI) The VCCI provides clinical case management and support services to the most high-cost Medicaid beneficiaries in order to better manage their health care. The Vermont Chronic Care Coordinators are intended to supplement core CHT functions by providing intensive case management to the most high-cost Medicaid beneficiaries. Functional CHT: Interface with area health and human services providers The Blueprint Core CHT is a unique interdisciplinary team designed to support the general population served by participating primary care practices. The Grantee shall help to ensure coordination of care by supporting a Functional CHT consisting of key local health and human services providers and to ensure that services are efficiently rendered and not duplicated. Key local providers include include, but are not limited to to, the local Home Health Agency, Designated Mental Health Agency, addictions treatment providers, Children’s Integrated Services (CIS) team, and Enhanced Family Services (EFS) team. Grant Deliverables