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Building the Digital Infrastructure for Vermont’s Learning Health System ONC HIT Policy Committee Testimony September 14, 2011 Hunt Blair, Deputy CommissionerDivision of Health ReformDepartment of Vermont Health Access (Medicaid)
Building a Paradigm for “Systemness” • We do not distinguish between HIT/HIE and health reform; we have an integrated strategy to support a foundation of Advanced Primary Care and Community Health Teams known as The Vermont Blueprint for Health – and which we’ll next expand to include Accountable Care Partnerships. • The Blueprint’s design principles: • All Vermonters should have a Blueprint for Health primary care provider • All Blueprint for Health providers are supported by Community Health Teams that have nurses and specialists in nutrition, exercise, counseling and more to support individuals to lead healthier lives. • Specialty care is fully integrated with the patient’s Blueprint Providers and Community Health Team. • Blueprint Providers and Community Health Teams are able to address the population health needs of their communities. • Fragmentation of care should be a “never event.”
“Systemness” Extends to the State Enterprise • Extending that logic: fragmentation of state-sponsored health and human services for adults and children should be a “never event” and HIE is the vehicle to ensure that. • Better together, or the Vermont “Ben & Jerry’s factor” to mix in lots of yummy ingredients in tasty combinations: we haven’t met systems we can’t integrate & improve • SOA framework supports technical integration that helps model programmatic integration • Building a distributed networkultra-large scale system of systems where the State supports and helps to provide the system structure / framework for better integrated health care and human services
VT Blueprint Continuum of Care – General Health Services Higher Acuity & Complexity Targeted Services for Complex Cases Community Health Teams Augmented by SASH Teams & Medicaid Care Coordinators • Specialty Care • Advanced Assessments • Advanced Treatments • Advanced Case Management • Social Services • Economic Services • Community Programs • Self Management Support • Public Health Programs • Support Patients & Families • Support Practices • Coordinate Care • Coordinate Services • Referrals & Transitions • Case Management • Medicaid Care Coordinators • Senior Services Coordinators • Self Management Support • Counseling • Population Management Advanced Primary Care Practice Medical Homes Level of Need • Health Maintenance • Prevention • Access • Communication • Self Management Support • Guideline Based Care • Coordinate Referrals • Coordinate Assessments • Panel Management Lower Acuity & Complexity Locus of Service & Support
Blueprint Supported by an HIT “neural network” Specialized & Targeted Services Community Health Teams Including SASH Teams & Medicaid Care Coordinators Advanced Primary Care Practice Medical Homes Covisint / DocSite Clinical Repository, VT HIE Network & AHS Enterprise Architecture Connectivity across the continuum