Models of Care - OneCare Vermont

Models of Care

Network Model

The participant network is a clinically integrated network across the state of Vermont. The participant network will use a common methodology and toolset for all providers. However, most of the actions and initiatives required for improving performance will be determined and implemented at the local level as defined by specific geographies and local providers. It is anticipated that some clinical protocols and procedures will have universal application and will be required for all ACO network participants. OneCare Vermont’s focus on and accountability for the quality performance measures will drive these decisions.

Participation in the OneCare Vermont network offers providers and provider organizations an opportunity to partner with the founding organizations and other network participants. OneCare Vermont and the network participants will develop a comprehensive support structure of tools and methodologies to accomplish the goals of the MSSP. Among the obligations for network participants will be the sharing of clinical data to be unified with the Medicare claims information that will be provided to OneCare Vermont by Medicare. This data will help measure the ongoing experience across the quality performance measures and help us identify attributed Medicare beneficiaries requiring individual care coordination attention. It is also expected that network participants will assign or provide staff to conduct the care coordination processes and use the tools provided by OneCare Vermont.


OneCare Vermont is a Vermont Limited Liability Company formed in May 2012 by The University of Vermont Medical Center and Dartmouth-Hitchcock Health (“DartmouthHitchcock”) for the purpose of applying for the MSSP. OneCare Vermont is governed by a Board of Managers and a Clinical Advisory Board charged with establishing a clinical model to monitor and improve clinical performance. The University of Vermont Medical Center and Dartmouth-Hitchcock, as corporate equity members and financial sponsors of OneCare Vermont, will maintain majority status on the Board of Managers. The Board of Managers has been designed to consist of eleven members, three each named by The University of Vermont Medical Center and Dartmouth-Hitchcock, one Medicare beneficiary as required by CMS, and four members designed to represent the OneCare Vermont network participants other than The University of Vermont Medical Center and Dartmouth-Hitchcock. A supermajority of 75% board approval is required for material decisions and financial commitments.

OneCare Vermont has developed a Clinical Advisory Board elected by OneCare Vermont network participants that establishes, reviews, and manages the clinical model. The Clinical Advisory Board also acts as the primary monitor of performance, sets priorities among areas of opportunity, and implements programs for improvement. The Clinical Advisory Board includes a broad representation of clinical leaders from throughout the OneCare Vermont network participants and, depending on the level of statewide participation and attributed lives, may be designed as regional boards that come together for statewide planning on a periodic basis. It is our intent to design key elements of the Clinical Advisory Board approach in collaboration with the OneCare Vermont network participants in January 2013.

Clinical Model

The clinical model to be developed in consultation with the Clinical Advisory Board will have three inter-related and mutually supporting elements:

  1. Care Coordination OneCare Vermont intends to build upon the strengths of the Primary Care Medical Home (“PCMH”) model in Vermont. The overarching principle of the OneCare Vermont clinical model is that care coordination efforts should be provided as close to the point of care (PCMH or Specialty Practice) as is practicable. Effectiveness in care coordination has been shown to improve quality outcomes and cost when “embedded” in the provider practice either through the PCMH or the Community Health Team.

    OneCare Vermont envisions the network participants through the Clinical Advisory Board and Committees will identify clinical quality improvement initiatives. In doing so, the network participants will assign or provide resources to perform care coordination functions for their Medicare beneficiaries. OneCare Vermont will assist in the development of toolsets and training in an effort to assist the network participants when appropriate. OneCare Vermont may also contract with network participants on an added “per member per month” basis, to make available care coordination services to network participants that do not have the infrastructure or resources to provide the service, or for practices that are not yet Primary Care Medical Homes or large enough to support the care coordination function. OneCare Vermont will also provide centralized care coordination for attributed Medicare beneficiaries who are either highly complex or have intensive coordination needs, such as transplant patients.
  2. Clinical Data Sharing Network participants will be required to submit or provide access to clinical data in their Health Records systems for attributed Medicare beneficiaries in order to support analysis and improvement of evidence-based medicine, quality outcomes, and to provide access to a more complete clinical record and history for Medicare beneficiaries across the OneCare Vermont participant network.
  3. Quality Measure Management OneCare Vermont will monitor and seek to improve performance for the Medicare-defined quality performance measures and other quality measures. OneCare Vermont will provide the analytical tools and resources to collect, track, and report process and outcomes measures that will assist us in identifying improvement opportunities for our attributed population