Vermont Hub and Spokes Health Homes

Vermont has an approved state plan amendment for a 2703 Medicaid Health Home program. The Hub and Spokes Health Homes program creates a coordinated, systemic response to the complex issues of opioid addiction among Vermont's Medicaid population, focusing specifically on medication assisted therapy (MAT) for individuals with opioid dependence. The Hub and Spoke approach builds on the statewide expansion of Advanced Primary Care Practices (APCP) also known as Patient Centered Medical Homes, supported by core Blueprint for Health Community Health Teams (CHT) and CHT extenders. This model has allowed Vermont to establish a novel foundation for high quality primary care with embedded multidisciplinary support services, better coordination and transitions of care, and more seamless linkage among the multitude of partners from many disciplines.

As a public-private partnership, the Blueprint has existing CHTs comprised of nurse coordinators, clinician case managers, social workers and other professionals who extend the capacity of primary care practices to assess patients' needs, coordinate communitybased support services, and provide multidisciplinary care. Effective teams are the basis for all of the quality improvements in the Blueprint, supported by payment reforms that provide patients and practices with unhindered access to CHTs, CHT extenders and Self-Management opportunities.

• Hub: Registered nurse and master’s level licensed clinician case manager, and program director employed by the Hub
• Spoke: Registered nurse and clinician case manager employed by Blueprint Community Health Team