Care Coordination

OneCare’s care coordination model supports care teams in communities across Vermont.

Care coordination requires a strong relationship between the patient, their primary care provider, and other members of a person’s care team. OneCare provides tools and resources to help facilitate this coordination. With OneCare tools and support, providers work together across organizations to help patients access the care they need and avoid expensive duplicate services. Providers share information about what is happening with the patients they are all caring for—if the person is admitted or discharged from the hospital, if social or economic factors put patients at risk, or if a change in their mental health has occurred. That way, providers caring for the same patient can quickly identify ways to address their needs and the patient only has to tell their story once.

OneCare provides the following to support care coordination:

  • Data to help inform primary care providers which patients on their panel may benefit from care coordination
  • Best practices and tools for forming a community- and team-based care coordination model
  • Secure communication tools care coordination team members can use no matter where they work
  • Training for health care workers and partners statewide on care coordination processes and procedure