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Issue

Vermont established a team-based standard for supporting populations with complex needs but found that it was not being implemented consistently across healthcare and human services. They were looking for assistance establishing these new practices in six departments across the state.

Program goals

To support statewide implementation of Vermont Team-Based Care (VTBC) across the six departments under the Vermont Agency of Human Services (AHS), including codifying the model and expanding it to programs and departments that were not previously part of team-based care.

To do this, we worked with AHS to:

• Convene local stakeholders in each health service area to reenergize the VTBC model
• Document and improve local workflows and practices
• Strengthen the governance structure of the VTBC model
• Create online, self-paced trainings for frontline community provider staff statewide who are delivering VTBC for populations with complex health and social needs

About VTBC

Vermont Team-Based Care (VTBC) is a philosophy and set of individual and system-level practices to support people who have chronic health, mental health, substance use, and/or social needs. At its foundation, VTBC allows healthcare and human services organizations to work together in partnership with individuals and families to identify needs, access appropriate resources and services, and support progress towards individual goals.

The VTBC philosophy describes the way healthcare and human services are delivered to all, not just specific populations. It is:

• Trauma-responsive
• Person-centered
• Collaborative across disciplines and sectors to support people in their medical, mental health, substance use, and social needs
• Used at every entry point into the system of care

Agency staff and providers screen for needs so that people may be connected to support. The goal is to be more proactive in care, help people reach their goals, and rebuild trust among the community.

The VTBC individual practices include assessing biopsychosocial needs, helping identify goals, connecting to services and benefits, and supporting behavior change to reach those goals. The intensity of care coordination in VTBC varies based on how much help someone needs and how complex their situation is. VTBC also includes collaborative practices among providers such as establishing lead care coordinator, creating a shared care plan, and conducting care team meetings, to ensure they are working as a team to achieve shared goals defined by the individual.

Background

Vermont Agency of Human Services (AHS) has a strong history of supporting individuals with complex medical and social needs through community-based initiatives. It is committed to aligning relevant programs with the tenets of whole person, cross-sector, team-based care to serve populations with very complex needs. The small, rural state takes pride in their culture of collaboration, both at the community and state levels.

AHS’ jurisdiction is broad, including child welfare, corrections, disabilities, and mental health. This means they needed a cross-sector approach to service delivery and quality improvement. In 2014, Vermont launched the Integrated Communities Care Management (ICCM) Learning Collaborative, a statewide effort to improve care for individuals with complex needs, with support from the Camden Coalition. Though the initiative’s funding ended in 2017, the care coordination tools and team-based approaches derived from the ICCM collaborative, including the care planning cards developed at the Camden Coalition, are still used across the state.

In the last two years, with the help of the Camden Coalition, Vermont has focused on making this a multi-sector approach across all of healthcare and human services in the state. In 2024, the model was formally named Vermont Team-Based Care (VTBC).

VTBC is supported by a statewide infrastructure, including the Blueprint for Health, AHS Field Directors, and Blueprint Community Health Teams, which provide the backbone for community- and state-level service delivery and quality improvement.

Project design

In 2023, the Camden Coalition evaluated VTBC, previously called “complex care,” and recommended changes to make it more inclusive and aligned across all departments within AHS.

In 2024, the Camden Coalition supported Vermont AHS to launch an effort to reinvigorate VTBC at the community level across all AHS contracted providers and to further define expectations for care providers. The Camden Coalition systematically documented best practices in VTBC through a statewide learning collaborative and an online, self-paced training on the core elements and practices of VTBC.

To develop the training, the Camden Coalition convened a Curriculum Advisory Committee comprised of frontline and leader experts from across the state and various sectors. This not only ensured that the curriculum was customized to Vermont’s language, population, and unique challenges, but also built relationships and deepened collaboration.

In a learning collaborative of Vermont’s 14 geographic health service areas (HSAs) running through April 2025, each HSA is focusing on 1-2 priorities for improvement. Change teams in each area are testing efforts to improve quality of care, with support from the Blueprint team, a Field Director, and expert facilitators from the Camden Coalition. Teams from across the state are convening three times during the learning collaborative to share updates and best practices.

Examples of health service area priorities for change:

• Restart a structured community-wide team-based case conference/care coordination meeting
• Adopt FindHelp tool to increase access to coordinated services
• Improve collaboration between service providers working with people who frequent interact with emergency services
• Implement training and structures to increase trauma-healing organization, systems, and communities
• Strengthen supports across the continuum of care for people with complex needs and housing instability
• Expand organizational participation in VTBC by developing MOUs that outline roles and responsibilities of organizations participating in VTBC, producing client-facing language on VTBC, and setting VTBC ideals as quality improvement roadmap for our community

The Camden Coalition also coached department leaders through statewide implementation and change management processes including communications, policy and evaluation. The intent was to help codify and expand the capabilities of VTBC to foster sustainability and efficiency.

Progress to date

Learning collaborative

From May 2024 through April 2025, we helped to strengthen each HSA’s Blueprint Program and Field Director dyads to lead their communities in ongoing system-level coordination and quality improvement. The strategies varied by each area but included efforts to forge meaningful relationships between the two positions, establish regular meetings, define clear roles and responsibilities from each position, and identify collaborative opportunities on new or ongoing work.

The Camden Coalition documented best practices to share with HSA leadership to ensure sustainability of the model through staff turnover and other changes.

Curriculum

We co-created four self-paced courses with a Vermont-based advisory committee between May 2024 and March 2025. The four courses are:

• Team-based care 101
• Team-based care approaches and tools
• Shared care planning
• Sharing information

The courses will train staff across AHS and other team-based care programs.

Implementation support

We worked with all six of Vermont AHS departments to build internal knowledge and support of VTBC and map their programs to VTBC program designations. We also supported the creation of a communications plan from AHS leadership to VTBC implementers across the state about the reinvigoration and expansion. We also documented the model, workflows, and practices of VTBC to standardize implementation.

We also worked with a cross-state and multi-organizational steering committee to support the strengthening of VTBC at the agency and department level.

Contact us

Alexandra Lipira
Senior Program Manager, Field Building & Resources: [email protected]