Cover Image - COVID-19 App Presented at the Health Analytics Summit 2020, showing Tyler Gauthier and Katie Muir as presenters

An Introduction to Care Coordination

Care coordination plays a critical role in OneCare’s goals to transform the health care delivery model by improving health outcomes for Vermonters while stabilizing health care costs – and this strategy is more relevant than ever during these uncertain times due to the COVID-19 pandemic. Care coordination provides high-quality, person-centered, community-based care services across different health care providers in an integrated delivery system to achieve optimal health outcomes. Click here to read Tom’s story as an example of care coordination with successful outcomes (tip: scroll down to the “Overall, how will Vermonters benefit from OneCare?” section).

In 2019, providers in OneCare increased the number of high and very high risk patients actively engaged in care coordination by 600% to nearly 4,000 people

Cooperation is at the core of care coordination, in which thousands of providers share resources and expertise to keep Vermonters healthy and well. A care team may consist of different types of providers and organizations – such as Area Agencies on Aging, SASH, and home health: essentially the combination that works best for a Vermonter who needs the support care.  OneCare provides the care team with communication tools, best practices, and resources to optimize better health.

The Latest in OneCare’s Care Coordination Work

The care coordination team at OneCare have been providing technical assistance, education, training and support to the hard-working network of care coordinators who care for patients.

OneCare sponsors 95 care coordinators for a three-day workshop in preparation to take the Board Certified Case Manager exam by the end of 2020

On Monday, September 14, 2020, Jenn Gordon, OneCare’s program supervisor, kicked off a three-day workshop by giving a presentation about the sponsorship opportunity for nearly 100 care coordinators statewide to increase board certified case manager capacity.

Board-certified case managers are essential for organizations who serve patients who need help with navigation, care coordination, and access to resources for optimizing health. Certified case managers bring value through specialty expertise in areas such as rehabilitation, chronic diseases management, geriatrics, care transitions, managed care, home care, and more. The majority of case managers who receive this certification are registered nurses (88%). Another 8% have professional experience in social work, and 4% have professional experience in workers’ compensation. The benefits of certified case managers for organizations are apparent – organizations will typically see increased quality of the patient experience, a reduction in 30-day hospital readmission rate, cost savings, and reduction in emergency department visits. (Source: Health2 resources and CCMC, Professional and Demographic Characteristics of CCMS, February 2019).

Achieving board certification means that a typical certified case manager is able to demonstrate expertise, rigorous knowledge, and professional experience. It also establishes a code of professional conduct for case managers.

The response has been overwhelmingly positive. In less than a month after offering this opportunity, we were near capacity with representation from almost every local health service. The case manager board certification demonstrates expertise, rigorous knowledge and professional experience including a standard of conduct. By the end of this year, we’re hopeful that Vermont will have nearly 80 more board certified case managers than it did last year. This is aligned with OneCare’s vision to create a system of care in which all Vermonters have access to high-quality, evidence-informed, integrated, community-based care coordination, across the continuum to achieve optimal health outcomes.

Jenn Gordon

LICSW, CPHQ Supervisor, OneCare's Care Coordination Program

About the Certified Case Manager Workshop/Exam Sponsorship Opportunity:

A unique sponsorship opportunity was made available through OneCare for individuals who are coordinating care for accountable care organization (ACO) members on behalf of participating ACO organizations such as primary care practices and community-based organizations. OneCare partnered with the Commission for Case Manager Certification (CCMC) to bring the first virtual three-day exam preparation workshop to Vermont in September so that in December 2020, workshop attendees will be fully prepared to pass the certification exam to become board certified case managers (CCM). Vermont will have approximately 80 newly certified case managers in our workforce.

Jenn Gordon said, “The case manager credential demonstrates a proven knowledge to practice case management. It says that you are top in your field. Vermonters will be better served by a workforce who  demonstrate enhanced competency and skills. On behalf of OneCare, we are grateful to our committed network of care coordinators who are doing the challenging work of supporting individuals during vulnerable times.”

Through this sponsorship opportunity, OneCare will offer selected eligible care coordinators the following:

  • A virtual customized educational workshop
  • A one-year subscription to the Case Management Body of Knowledge
  • Optional exam preparation sessions
  • Access to the online practice exam
  • Partial payment toward the cost for the certification examination

Once an individual becomes certified, s/he has access to the CMLearning Network including a database of research, case examples and the latest on regulatory changes, ethics, and current trends.

A slide discussing racial disparities among COVID cases from the presentation. The introduction indicates white Vermonters represent the majority of COVID-19 cases. African American Vermonters have the highest rate; with the rate being "per 10,000 Vermonters." A pie chart reflects the percentage of cases by race, and a bar chart reflects the rate of cases by race.

Care Coordination Corner Course Launches on Vermont Health Learn

In the ongoing effort to create a system of care in which all Vermonters have access to high quality, evidence-informed, integrated community-based care coordination, OneCare is offering relevant education to the workforce of coordinators caring for Vermonters. This education will include information, resources, and tools on best practices related to complex care management in the newly created “Care Coordination Corner” on Vermont Health Learn, the online learning platform OneCare launched in partnership with the Vermont Department of Health and the Blueprint last year.

OneCare has provisioned all core team members and over 800 care coordinators from across the state to access the Care Coordination Corner on Vermont Health Learn. Educational offerings include the list below with two “Motivational Interviewing” modules scheduled to be added in the next two months.

  • Getting SMART about SMART Goals
  • Planning and Facilitating an Effective Care Team Conference
  • Words Matter: Using Person-Centered Language
  • OneCare’s Social Risk Score: Supporting Population Health Management
  • The Medicaid Expanded Population

If you are interested in suggesting a particular topic or for more information, please contact OneCare’s care coordination team at

The number of care coordinators across Vermont served by the Care Coordination Corner on Vermont Health Learn

Coming Up Next For Care Coordination

  • October 30 – Joint Core Team Meeting
  • November – TBD – Optional Exam Preparation
  • November 4 – Motivational Interviewing
  • December – TBD – Board Certified Case Manager Examination

For more information:

Please contact Public Affairs at OneCare Vermont. | 802-847-1346

To stay up to date on OneCare, please visit our news blog and our social media channels on LinkedIn and Twitter.