Network Performance Management

OneCare brings together thousands of health care providers across the state who have all committed to working better together to improve care.

OneCare doesn’t deliver health care – we bring data and innovative payment programs to health care providers to improve performance. Network performance management is at the core of accountable care. By bringing providers together, sharing data that help providers give better care and see how they compare, and making predictable investments to stabilize health care costs, OneCare manages performance of the provider network.

One important aspect of performance management is quality. Stabilizing costs must be paired with improving quality and health outcomes over time to ensure patients receive excellent care. Quality measures ensure providers are monitoring, and striving to improve, health outcomes. Health care organizations with high scores on standardized measures of quality earn funding for innovative programs and health promotion efforts.

OneCare’s partnership with providers across the full spectrum seeks to address physical, mental, and social factors of a person’s health and wellbeing. We unify people across different aspects of care to focus on the patient.  This “whole person approach” by the full care team supports Vermonters to meet their health goals. Every stage and phase of health and the care you receive from your provider is customized for you to yield the best care outcome and experience. Better coordination as a health care team to address people’s total health and wellness needs is key to lowering unnecessary health care costs, improving outcomes, and a better patient and caregiver experience.

Larger Version Illustration - OneCare Core Business Area - the Statewide Care Model - showing a doctor taking care of a male patient checking his heart beat with a stethoscope. Next to the patient is a window showing Vermonters in healthy communities engaging in activities promoting healthier lifestyles.

Healthy Communities

OneCare Vermont’s approach is designed to improve health care outcomes and the quality of care received in the doctor’s office and all clinical settings. Our network doesn’t stop there, however, because we know that a patient’s physical environment, social and economic factors, and health behaviors really add up to impact both length and quality of life. Looking at all of these factors that influence a Vermonter’s health, only 20% are influenced by clinical care. This is where RiseVT comes in to work in communities on policies and programs that implement health behavior change interventions and address the social, economic, and physical environment factors that impact health.

Care Coordination

OneCare convenes providers to give excellent care at a stable cost. Care Coordination requires a strong relationship between the patient, their primary care provider, and other members of a person’s care team. Primary care providers are vital as the patient’s medical home. OneCare’s care coordination model supports care teams in communities. That means many types of providers are connected to communicate more effectively as a team to care for the whole patient. They also work to ensure the patient can be connected to other supports, such as social services and mental health care, as needed. Because providers are working together across organizations, they can help patients access care they need and avoid expensive duplicate care services.

OneCare provides a secure communication tools, like Care Navigator, to link providers across organizations. Using the tool, providers share information about what is happening with the patients they are 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.

Fred’s Story: A Case Study of Care Coordination

Helping Vermonters through Care Coordination

Using data analytics from OneCare, providers can see across all patients they care for and identify those who may benefit from care coordination. A care team across primary care and specialty care then works with the patient to help them identify health goals, to connect patients to health care and other services, and to partner with patients as they work toward their goals.

Health care providers and partners coordinate to give direct care and work in teams to care for patients. 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 on 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 procedures

Primary Prevention for Low and Medium Risk Vermonters

In 2021, OneCare’s budget invests over $30 million in primary care and population health management efforts. These efforts include:

  • RiseVT community-wide prevention and health promotion efforts
  • To offer preventative health care to our youngest Vermonters, Developmental Understanding and Legal Collaboration for Everyone (DULCE) is an intervention model that takes place within pediatric care offices to address health in infants ages zero to six months and to provide parental support. OneCare has helped expand new DULCE sites after their initial pilot in Vermont and the new sites are currently working to expand the program and further integrate within pediatric practices.