January 2015

4th Edition

Bi-State Primary Care Association 61 Elm Street, Montpelier, Vermont 05602 (802) 229-0002 www.bistatepca.org

Vermont Primary Care Sourcebook

January 2015

Acknowledgements

Special thanks to our Vermont Bi-State Members for providing high quality health care in their communities and data for this Sourcebook.

We welcome your questions. For more information, please contact:

Sharon Winn, Esq., MPH, Director of Vermont Public Policy Bi-State Primary Care Association 61 Elm Street Montpelier, Vermont 05602 802-229-0002 [email protected]

Or look for us at: www.bistatepca.org

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Sourcebook Index Document Title Page # Acknowledgements i

About Bi-State Primary Care Association 1

Bi-State Primary Care Association Membership Map 2

Bi-State’s 81 Member Sites by County 3

Bi-State Primary Care Association’s 82 Vermont Member Sites 4

Vermont Bi-State Primary Care Association Member Contacts 5

The Three Guiding Principles of the VT Primary Care Sourcebook 6

Vermont Health Centers Increase Access 7

Vermont Health Centers and Clinics Provide Care to 1 in 3 Vermonters 8

Vermont FQHCs Growth Since 2000 9

Rural Health Clinics: Ensuring Access in Rural Areas 10

Planned Parenthood of Northern New England 11

The Vermont Coalition of Clinics for the Uninsured: An Important Safety Net Provider 12

Vermont Area Health Education Centers (AHEC) 14

Vermont AHEC Approach to Increasing the Health Care Workforce 15

Attracting and Retaining a Primary Care Workforce to Care for Vermont Residents 16

The Recruitment Center: A Service of Bi-State Primary Care Association 17 Vermont Migrant Farmworkers: Partners working in collaboration to ensure access to 18 health care Supporting Vermont Health Connect Outreach & Enrollment 19

Telemedicine in Rural Areas: Clinical, Educational, and Networking Collaborations 20

Vermont Health Centers Manage Costs 21

Community Health Accountable Care 22

Studies Demonstrate FQHCs Manage Costs 23

Vermont FQHCs Benefit the State & their Communities 24

FQHC Funding and Reimbursement Structure Minimizes Cost Shifting 25

Vermont Health Centers Improve Quality 26

ii Vermont Health Centers Recognized as Patient Centered Medical Homes (PCMH) by 27 the National Committee for Quality Assurance (NCQA) Vermont Health Centers with Fully Implemented Electronic Health Records (EHR) and 28 Attesting for Meaningful Use (MU) FQHCs Youth Programs 29

FQHC Federal Requirements Defined 31

FQHCs Ensure Access in their Communities 32

FQHCs Provided Primary Care to 153,000+ Vermonters in 2013 33

What is the FQHC Sliding Fee Scale? 34

Vermont Member Legislative Representation List by Legislator 35

Common Acronyms 42

iii

Vermont Primary Care Sourcebook

January 2015 About Bi-State Primary Care Association

Mission Promote access to effective and affordable primary care and preventive services for all, with special emphasis on underserved populations in Vermont and New Hampshire. Vision

Healthy individuals and communities with quality health care for all.

What we do

Established in 1986, Bi-State Primary Care Association, serving Vermont and New Hampshire, is a nonprofit, 501(c)(3) charitable organization that promotes access to effective and affordable primary care and preventive services for all, with special emphasis on underserved populations in New Hampshire and Vermont.

Bi-State members include Federally Qualified Health Centers, Community Health Centers, Rural Health Clinics, private and hospital-supported primary care practices, Community Action Programs, Health Care for the Homeless, Area Health Education Centers, Clinics for the Uninsured, and social service agencies.

Bi-State’s nonprofit Recruitment Center provides workforce assistance and candidate referrals to Federally Qualified Health Centers, Rural Health Clinics, and private and hospital-sponsored physician practices throughout Vermont and New Hampshire. The Recruitment Center focuses on the recruitment and retention of primary care providers including physicians, dentists, nurse practitioners, and physician assistants.

Bi-State is a resource for employers and candidates regarding the eligibility requirements and availability of recruitment incentive programs such as state educational loan repayment, National Health Service Corps programs and “Conrad State 30.” (Conrad State 30 allows the Vermont Department of Health to sponsor a certain number of international medical graduates each year for the waiver of the two-year home residency requirement of the physician’s J1 visa.)

With offices in Vermont and New Hampshire, Bi-State works with federal, state, and regional health policy organizations, foundations, and payers to develop strategies, policies, and programs that provide and support community-based primary health care services in medically underserved areas.

Bi-State Primary Care Association 61 Elm Street, Montpelier, VT 05602 (802) 229-0002 www.bistatepca.org

1

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Vermont Primary Care Sourcebook

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Bi-State’s 82 Member Sites by County

Addison County Orleans County  The Open Door Clinic (V)  North Country Health Systems  Middlebury Health Center (P) o Community Medical Associates  Mountain Health Center o Family Practice of Newport  Mountain Health Center Annex o North Country OB/GYN Services Bennington County o The Barton Clinic  Bennington Free Health Clinic (V) o Orleans Medical Clinic  Bennington Health Center (P)  Newport Pediatrics and Adolescent Medicine  Battenkill Valley Health Center  Newport Health Center (P) Caledonia County Rutland County  Northern Counties Health Care  Community Health Centers of the Rutland Region o Danville Health Center o Brandon Medical Center o Hardwick Area Health Center o Castleton Family Health Center o Northern Counties Dental Center* o CHCRR Pediatrics o St. Johnsbury Community Health Center o Mettowee Valley Health Center o Rutland Community Health Center  St. Johnsbury Health Center (P) o Shorewell Community Health Center Chittenden County o Community Dental Clinic*  Community Health Centers of Burlington  Rutland Free Clinic* (V) o Riverside Health Center*  Rutland Health Center (P) o Safe Harbor Health Center* o Pearl Street Youth Health Center Washington o H.O. Wheeler School (school-based)*  The Health Center  Health Assistance Program at Fletcher Allen Health Care (V) o The Health Center Main Site* o Cabot Health Services (school-based)  Burlington Health Center (P) o Ronald McDonald Dental Care Mobile*  Williston Health Center (P)  Gifford Health Care Essex County o Gifford Health Center at Berlin  Northern Counties Health Care  People’s Health & Wellness Clinic (V) o Concord Health Center  Barre Health Center (P) o Island Pond Health and Dental Center* Windham Franklin County  Putney Walk-In Clinic (V)  Northern Tier Center for Health  Brattleboro Health Center (P) o Enosburg Health Center o NCSS Health Center  Springfield Medical Care Systems o Richford Health Center o Rockingham Medical Group o Richford Dental Clinic* Windsor o St. Albans Health Center  Springfield Medical Care Systems o Swanton Health Center o Chester Family Medicine o NoTCH Dental Clinic* o The Ludlow Health Center  St. Albans Health Center (P) o The Ludlow Dental Center* Grand Isle County o Springfield Health Center o The Women’s Health Center of Springfield  Northern Tier Center for Health o Alburg Health Center  Gifford Health Care o Bethel Health Center  Community Health Centers of Burlington o Rochester Health Center o Keeler Bay Health Center o Twin River Health Center Lamoille County  Good Neighbor Health Clinic and  Community Health Services of Lamoille Valley Red Logan Dental Clinic* (V) o Morrisville Family Health Care  Valley Health Connections (V) o Behavioral Health & Wellness Center  Windsor Community Clinic (V) o Stowe Family Practice o Community Dental Clinic* Sullivan County, NH o Appleseed Pediatrics  Springfield Medical Care Systems  Hyde Park Health Center (P) o Charlestown Family Medicine (NH) Orange County  Gifford Health Care o Chelsea Health Center o Gifford Primary Care  Little Rivers Health Care o LRHC at Bradford o LRHC at Wells River o LRHC at East Corinth o Clara Martin Center o Valley Vista  Health Connections at Gifford Medical Center (V)

Increase Access *site provides dental services (V): VCCU Clinic (P): PPNNE Clinic 3

Vermont Primary Care Sourcebook

January 2015 Bi-State Primary Care Association’s 82 Vermont Member Sites by Organization Battenkill Valley Health Center North Country Health Systems (FQHC) (RHC) 1. Battenkill Valley Health Center 1. The Barton Clinic Community Health Centers of Burlington 2. Community Medical Associates (FQHC) 3. Family Practice of Newport 1. Keeler Bay Health Center 4. North Country OB/GYN Services 2. Riverside Health Center* 5. Orleans Medical Clinic 3. H.O. Wheeler School (school-based)* Northern Counties Health Care 4. Pearl Street Youth Health Center (FQHC) 5. Safe Harbor Health Center* 1. Concord Health Center Community Health Centers of the Rutland Region 2. Danville Health Center (FQHC) 3. Hardwick Area Health Center 1. Brandon Medical Center 4. Island Pond Health & Dental Center* 2. Castleton Family Health Center 5. The St. Johnsbury Community Health Center 3. CHCRR Pediatrics 6. Northern Counties Dental Center* 4. Mettowee Valley Health Center Northern Tier Center for Health 5. Rutland Community Health Center (FQHC) 6. Shorewell Community Health Center 1. Alburg Health Center 7. CHCRR Community Dental* 2. Enosburg Health Center Community Health Services of Lamoille Valley 3. NCSS Health Center (FQHC) 4. Richford Health Center 1. Behavioral Health & Wellness Center 5. St. Albans Health Center 2. Morrisville Family Health Care 6. Swanton Health Center 3. Community Dental Clinic* 7. NoTCH Dental Clinic* 4. Stowe Family Practice 8. Richford Dental Clinic* 5. Appleseed Pediatrics Planned Parenthood of Northern New England Gifford Health Care (Women’s Health Services) (FQHC) 1. Barre Health Center 1. Bethel Health Center 2. Bennington Health Center 2. Chelsea Health Center 3. Brattleboro Health Center 3. Gifford Health Center at Berlin 4. Burlington Health Center 4. Gifford Primary Care 5. Hyde Park Health Center 5. Rochester Health Center 6. Middlebury Health Center 6. Twin River Health Center 7. Newport Health Center The Health Center 8. Rutland Health Center (FQHC) 9. St. Albans Health Center 1. The Health Center Main Site* 10. St. Johnsbury Health Center 2. Cabot Health Services (school-based) 11. Williston Health Center 3. Ronald McDonald Dental Care Mobile* Springfield Medical Care Systems Little Rivers Health Care (FQHC) (FQHC) 1. Chester Family Medicine 1. LRHC at Bradford 2. The Ludlow Health Center 2. LRHC at East Corinth 3. Rockingham Medical Group 3. LRHC at Wells River 4. Springfield Health Center 4. Clara Martin Center 5. The Women’s Health Center of Springfield 5. Valley Vista 6. The Ludlow Dental Center* Mountain Health Center 7. Charlestown Family Medicine (NH) (FQHC) Vermont Coalition of Clinics for the Uninsured (Free Clinics) 1. Mountain Health Center 1. Bennington Free Health Clinic 2. Mountain Health Center Annex 2. Good Neighbor Health Clinic and Red Logan Dental Clinic* Newport Pediatrics & Adolescent Medicine 3. Health Assistance Program at Fletcher Allen Health Care (RHC) 4. Health Connections at Gifford Medical Center 1. Newport Pediatrics 5. The Open Door Clinic 6. People’s Health & Wellness Clinic 7. Putney Walk-In Clinic 8. Rutland Free Clinic* 9. Valley Health Connections 10. Windsor Community Clinic

* site provides dental services Increase Access FQHC = Federally Qualified Health Center; RHC = Rural Health Clinic 4

Vermont Primary Care Sourcebook

January 2015

Vermont Bi-State Primary Care Association Member Contacts

Battenkill Valley Health Center Newport Pediatrics & Adolescent Medicine Grace Gilbert Davis Thomas Moseley, MD 9 Church St., Arlington, VT 05250 121 Medical Village Drive, Newport, VT 05855 (802) 430-7269 (802) 334-5929 [email protected] [email protected]

Community Health Centers North Country Health Systems of Burlington Julie Riffon, Director of Quality and Care Jack Donnelly, MBA, CEO Management 617 Riverside Avenue, Burlington, VT 05401 186 Medical Village Drive, Newport, VT 05855 (802) 264-8149 (802) 334-2310, ext. 241 [email protected] [email protected]

Community Health Centers Northern Counties Health Care, Inc. of the Rutland Region Patrick Flood, CEO Grant Whitmer, Executive Director 165 Sherman Drive, St. Johnsbury, VT 05819 215 Stratton Rd, Rutland, VT 05701 (802) 748-9405 ext. 1519 (802) 773-3386 ext. 2081 [email protected] [email protected] Northern Tier Center for Health Community Health Services Pamela Parsons, Executive Director of Lamoille Valley 44 Main Street, Richford, VT 05476 Kevin Kelley, CEO (802) 255-5561 66 Morrisville Plaza, PO Box 749, [email protected] Morrisville, VT 05661 (802) 851-8607 Planned Parenthood of Northern New [email protected] England Meagan Gallagher, President/CEO Gifford Health Care 183 Talcott Road, Suite 101, Williston, VT 05495 Joseph Woodin, President/CEO (802) 448-9778 44 S. Main St, PO Box 2000, Randolph, VT 05060 [email protected] (802) 728-2304 [email protected] Springfield Medical Care Systems, Inc. Timothy Ford, CEO The Health Center 25 Ridgewood Road, Springfield, VT 05156 John Matthew, M.D., Director (802) 885-2151 P.O. Box 320, Plainfield, VT 05667 [email protected] (802) 454-8336 UVM College of Medicine Little Rivers Health Care Office of Primary Care and AHEC Program Gail Auclair, CEO Elizabeth Cote, Program Office Director 146 Mill St., PO Box 338, Bradford, VT 05033 UVM AHEC Program Office, UHC Campus Arnold 5 (802) 222-4637 ext. 104 1 South Prospect Street, Burlington, VT 05401 [email protected] (802) 656-0030 [email protected] Mountain Health Center Martha Halnon, Executive Director Vermont Coalition of Clinics for the 74 Munsill Avenue, Suite 100, Bristol, VT 05443 Uninsured (802) 453-5028 ext. 7214 Lynn Raymond-Empey, Director [email protected] PO Box 655, Bellows Falls, VT 05101 (802) 732-8253 [email protected]

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January 2015

The Vermont Primary Care Sourcebook is Organized by Three Guiding Principles

Purpose Statement: The Vermont Primary Care Sourcebook was developed as an informational tool for policy makers. This compilation of maps, data and information provides an overview of how Federally Qualified Health Centers and other Bi-State members increase access, manage costs, and improve the quality of primary care in Vermont.

Increase Access

Improve Manage Quality Cost

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Vermont Primary Care Sourcebook

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Increase

Access

Improve Manage

Quality Cost

Health centers increase access by:

Making high quality services available to patients, regardless of ability to pay or payment source

Offering sliding fee discounts based on income

Serving federally-designated Medically Underserved Areas and/or Populations (FQHCs & RHCs)

Providing interpretation, transportation, and other services that enable patients to access care

Offering extended hours, including evenings and weekends

Responding to unique service needs of the community

Supporting outreach and enrollment in Vermont Health Connect

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Vermont Primary Care Sourcebook

January 2015

Bi-State Member Health Centers and Clinics Provide Care to 1 in 3 Vermonters

Bi-State Vermont Members Include:  11 Federally Qualified Health Centers  6 Rural Health Clinics  11 Planned Parenthood of Northern New England Clinics  10 clinics for the uninsured, and  The Area Health Education Center Network

These health centers and clinics served as a medical home for more than 193,000 patients who made more than 730,000 visits in 2013.1 This includes:

52% of Vermont Medicaid enrollees2 34% of Vermont Medicare enrollees 47% of uninsured Vermonters

Bi-State Members’ Coverage Status Mix:

Uninsured 10% Medicare 18%

Insured 41% Medicaid 30%

1 2013 UDS Roll-Up Report; self-reported data for non-FQHCs 2 Data is based on the 2012 DFR VT Household Health Insurance Survey 8

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Vermont Primary Care Sourcebook

January 2015

Vermont Federally Qualified Health Centers Growth since 2000 “The goal shall be to ensure there are FQHC[s] . . . in each county in Vermont.” ~Act 71 of 2005, Section 277(f).

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Vermont Primary Care Sourcebook

January 2015

Rural Health Clinics: Ensuring Access in Rural Areas

In 1977 Congress passed the Rural Health Clinic Services Act (PL 95-210) with two main goals: improve access to primary health care in rural, underserved communities; and promote a collaborative model of health care delivery using physicians, nurse practitioners, 1 and physician assistants.

Rural Health Clinics (RHCs) are designated after meeting eligibility requirements and completing an application to the Center for Medicare and Medicaid Services. They must be located in a federally designated underserved area (MUA), or in Vermont, a “Governor Designated Secretary Certified Area.” RHCs can be public, private, or nonprofit, and either independent (free standing) or hospital- affiliated. RHCs generally offer a sliding fee scale to low income patients. RHCs are located in rural areas and must have a mid-level provider onsite at least 50% of the time.2

Vermont’s 14 Rural Health Clinics3

1. Cold Hollow Family Practice (Enosburg Falls) 2. Community Medical Associates* (Newport) 3. NVRH Corner Medical (Lyndonville) 4. Family Practice of Newport*

5. Grace Cottage Family Health (Townshend) 6. Mountain Valley Medical Clinic (Londonderry) 7. Newport Pediatrics and Adolescent Medicine* 8. North Country OB/GYN Services* (Newport) 9. Orleans Family Medicine*

10. Ryder Brook Pediatrics (Morrisville) 11. NVRH St. Johnsbury Pediatrics 12. The Barton Health Clinic* 13. NVRH Womens Wellness Center 14. NVRH Kingdom Internal Medicine

*Denotes Bi-State Primary Care Association member

1Starting a Rural Health Clinic: A How-To Manual. Health Resources and Services Administration. http://www.narhc.org/uploads/pdf/RHCmanual1.pdf, accessed 1/26/2012. 2 Rural Assistance Center, Rural Health Clinics. http://www.raconline.org/topics/clinics/rhc.php , accessed 1/26/2012. 3Vermont Rural Health Clinic List is based on best available data on 6/25/2012

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The Vermont Primary Care Sourcebook

January 2015

Planned Parenthood of Northern New England

Founded in 1965, PPNNE serves patients at 21health centers across Maine, New Hampshire, and Vermont. These health centers provide the highest quality care through a wide range of services for women and men, including cancer screening, birth control, and STD testing and treatment. PPNNE offers a sliding fee scale, making care accessible and affordable to anyone who walks through their doors.

In 2013, the 11 PPNNE health centers in Vermont provided care to 16,887 Vermonters with 25,875 patient visits. Included were:  Pap Tests – 2,272  Breast Exams – 3,553  Sexually Transmitted Disease tests – 28,383

“Two years ago I started my own business, which meant that I had to pay out-of-pocket for health insurance. The

business started out slowly, and the only monthly premiums I could afford were for a catastrophic plan with a $5,000 deductible, which didn't cover my annual exam, birth control, or doctor's visits. Planned Parenthood helped me find a less expensive prescription and they allowed me to pay on a sliding scale based on my income for the care I received. I've since been able to afford a better health insurance plan, but I still choose Planned Parenthood for the level of care they always provide.” - PPNNE patient

“I believe you go beyond the call of duty with your kindness, warmth, and genuine compassion.“ - PPNNE patient

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Vermont Primary Care Sourcebook

January 2015

The Vermont Coalition of Clinics for the Uninsured: An Important Safety Net Provider

The Vermont Coalition of Clinics for the Uninsured (VCCU) is an association of ten free clinic programs and two dental programs that provide care (on site or by referral) and assistance free of charge to patients without adequate medical and dental insurance. The clinics are located throughout the state and are supported by the work of volunteers, community hospitals, local fund-raising, and an annual grant from the State of Vermont. All patients are assessed for eligibility in a number of federal, state, and local health care programs. The VCCU provides outreach and enrollment as well as assistance with medical care, prescriptions, dental care, and other health needs, along with providing case management for each patient.

In 2014, VCCU:

 Served 8,340 patients with 4,222 medical visits (at the five free standing clinics) and 837 medical referrals directly into a medical home for care. Approximately half of those patients seen by VCCU clinics in 2014 were there for the first time.

 Provided enrollment assistance for 3,000 Vermonters for Vermont Health Connect, Vpharm, and Ladies First, with 3,595 follow ups for benefit renewal and 3,746 consults to discuss insurance coverage details.

 Provided 2,069 applications for sliding fee discounts and hospital charity care programs, while also making sure the patient’s health needs are addressed until they are insured, enrolled and referred to a medical home.

 Provided more than $350,000 in free or low-cost medications through samples, prescription vouchers, and pharmaceutical assistance programs.

 Provided more than 1,100 dental referrals and 846 referrals for labs and imaging.

 Assisted 946 Vermonters with applications for 3Squares, Fuel Assistance, and Reach Up. Also made referrals for housing assistance to ESD and other local housing support programs.

 Provided 24,919 services to uninsured and underinsured Vermonters.

 Leveraged each dollar of funding with more than $4 million of in-kind support including medications, labs, and hospital support.

A True Commitment to Every Member of the Community

"I am so grateful for the Health Assistance program... It has allowed my husband to stay on medication he has previously gone without. This program demonstrates a true commitment to the community and their wellbeing."

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Vermont Primary Care Sourcebook

January 2015 The Vermont Coalition of Clinics for the Uninsured Locations

FAHC Health Assistance Program Maya Thompson 128 Lakeside Ave., Suite 106, Burlington, VT 05401 (802) 847-6985; [email protected]

Good Neighbor Health Clinic and Red Logan Dental Clinic Dana Michalovis 70 North Main St., White River JCT, VT 05001 (802) 295-1868; [email protected]

Health Connections at Gifford Medical Center Michele Packard 38 South Main St., Randolph, VT 05060 FAHC Health Assistance Program (802) 728-2323; [email protected]

Open Door Clinic Heidi Sulis 100 Porter Drive, Middlebury, VT 05753 People’s Health and Wellness Clinic (802) 388-0137; [email protected]

Rutland Free Clinic (and Dental) Tony Morgan Open Door Clinic 145 State St., Rutland, VT 05701 Health Connections at Gifford (802) 775-1360; [email protected]

People’s Health and Wellness Clinic Peter Youngbaer Rutland Free Good Neighbor 553 North Main St., Barre, VT 05641 Clinic Health Clinic (802) 479-1229; [email protected]

Windsor Community Valley Health Connections Health Center Wilda Pelton 268 River St., Springfield, VT 05156 Valley Health (802) 885-1616; [email protected] Connections Putney Walk-In Clinic Pat Field 79 Main St., Putney, VT 05346 (802) 387-2120; [email protected] Putney Walk-In Clinic Windsor Community Health Clinic Bennington Free Clinic Samantha Abrahamsen 289 County Road, Windsor, VT 05089 (802) 674-7213

Bennington Free Clinic Sue Andrews 601 Main St., Bennington, VT 05201 (802) 447-3700; [email protected]

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Vermont Primary Care Sourcebook

January 2015

Vermont Area Health Education Centers (AHEC)

Vermont AHEC is a network of academic and community partners working together to improve the distribution, diversity, supply, and quality of the health care workforce in Vermont. Established in 1996, Vermont AHEC has a statewide infrastructure with a program office at the University of Vermont, College of Medicine (UVM-COM), and three regional centers. Vermont AHEC focuses on achieving a well-trained workforce so that all Vermonters have access to quality care, especially those who live in Vermont’s most rural and underserved areas.

Over the last two years, the UVM Office of Primary Care and the Vermont AHEC network:

Provided 4,839 Vermont youth with health care careers experiences;

Worked with 224 providers precepting health professions students;

Delivered continuing education to 3,258 health care professionals; and

Placed 20 physicians in Vermont communities.

Working to “Connect students to careers, professionals to communities, and communities to better health.” - Vermont AHEC Overview, 2011

For further information contact: the Office of Primary Care and Area Health Education Centers (AHEC) Program, UVM, College of Medicine, 802-656-2179, www.vtahec.org

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Vermont Primary Care Sourcebook

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Vermont AHEC Approach to Increasing the Health Care Workforce

MedQuest CollegeQuest Shadow Day An intense, one-week A statewide, 6-week A one-day educational residential program for summer health care event for ninth to twelfth tenth and eleventh enrichment program for grade high school graders. eleventh grade students students to explore the

MedQuest is focused on who are from modest- diversity of health care health care career income families, or who careers. are the first in their family development and skill The day is filled with building activities. to attend college. presentations and one job Students are exposed to a Program goals include shadow experience. Three variety of careers in introducing students to "Shadow Day" programs health care through health care professions in are offered each year at presentations, workshops, behavioral / mental local hospitals—Fletcher visits to local hospitals, health, pharmacy, and Allen Health Care for and three job shadows. primary care, and to Chittenden County

provide college students, Porter Medical preparation and Center for Addison enrichment to enhance County students, and students’ competitiveness Northwestern Medical for college entry. There is Center for Franklin County no cost to attend this students. program.

For further information contact the Office of Primary Care and Area Health Education Centers (AHEC) Program, UVM, College of Medicine, 802-656-2179, www.vtahec.org Information and content provided by the Vermont AHEC Program, UVM, College of Medicine.

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Vermont Primary Care Sourcebook

January 2015

Attracting and Retaining a Primary Care Workforce for Vermont Assuring an adequate primary care workforce to serve the health care needs of Vermonters requires investment to cultivate an environment that offers incentives for clinicians to live and work in the state. The primary care workforce includes family medicine physicians, general internists, pediatricians, OB-GYNs, physician assistants, and nurse practitioners. These primary care providers work closely with other providers including dentists, psychiatrists, psychologists, and social workers to ensure that patients receive appropriate treatment. Vermont is competing nationally with other states to attract a limited pool of primary care physicians. The State’s need for primary care clinicians will continue to grow as the current workforce moves toward retirement and practices see increased patient volume as a result of the State’s health reform.

Federally Qualified Health Centers (FQHCs) are part of the solution to recruitment and retention for Vermont. FQHCs are employers of choice for health professionals across the country. Clinicians working in FQHCs obtain malpractice insurance through the Federal Tort Claims Act, which reduces financial and administrative burdens on the individual provider. FQHCs contribute to the economy by creating jobs and purchasing local goods and services.

Recruiting with Retention in Mind - Finding the Right Fit Bi-State’s Recruitment Center is the only organization in Vermont that focuses on recruiting clinicians from outside of the state. The Recruitment Center conducts national marketing and outreach to identify clinicians who are interested in relocation. The Recruitment Center then screens and matches these clinicians with practices and communities where both their professional and family needs can be met. The Recruitment Center's screening and matching reduce the amount of time that practices spend in recruiting clinicians that are not a fit for their practice or community. Matching clinicians and their families with a community that is the “right" fit is critically important for provider retention.

Recruitment & Retention Incentives - Educational Loan Repayment Most primary care physicians start their careers with $150,000 or more in educational debt. Expansion of the Vermont Educational Loan Repayment Program is critical to the state's ability to attract and retain health professionals. Unlike the National Health Service Corps (NHSC), Vermont’s Loan Repayment Program is targeted to areas identified by our local communities where there are gaps in service. The NHSC uses nationally applied criteria that do not reflect Vermont's true need and make it difficult for clinicians in Vermont to access NHSC loan repayment . Additional investment in Vermont's Educational Loan Repayment Program is critical to the state's ongoing ability to attract and retain clinicians to where there services are most needed.

Strengthening the Economy - Spousal/Partner Employment Communities across Vermont are having difficulty in attracting and retaining primary care clinicians due to a lack of professional employment opportunities for their spouse/partner. Investments in the state's economic growth and in the development of a resource toolkit that employers can use to assist spouse/partners to obtain professional employment helps the state to attract and retain clinicians as well as qualified professionals for other industries.

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Vermont Primary Care Sourcebook

January 2015

The Recruitment Center: A Service of Bi-State Primary Care Association Dedicated to Recruiting Primary Care Providers to Rural and Underserved areas

The Recruitment Center, a service of Bi-State Primary Care Association, is the only nonprofit organization that conducts national marketing and outreach to primary care physicians, nurse practitioners and physician assistants specifically to attract and recruit them to Vermont. Dedicated to recruiting primary care providers to rural and underserved areas of the state where their services are most needed, the Recruitment Center screens practitioners to determine which communities and practices will best meet their personal and professional needs to support long-term retention.

Familiar with the health care business, cultural, educational, and recreational environment, the Recruitment Center staff has a wealth of knowledge to support the transition of newly recruited practitioners and their families. The Recruitment Center also provides technical assistance on programs that support recruitment such as the National Health Service Corps (NHSC), which offers loan repayment for clinicians who agree to practice in federally designated medically underserved areas.

The Recruitment Center collaborates with organizations across Vermont to maximize resources and avoid duplication. The Recruitment Center’s national marketing and outreach complements the pipeline and workforce development activities conducted by Vermont’s Area Health Education Centers (AHEC) and the Vermont State Dental Society. The Recruitment Center regularly engages with organizations, including: the Vermont Office of Rural Health and Primary Care, UVM College of Medicine Office of Primary Care and AHEC Program, Vermont Medical Society, Vermont Association of Hospitals and Health Systems, Vermont Nurse Practitioner Association, the Physician Assistant Academy of Vermont, the Department of Labor, and representatives from our local medical school, several hospitals, and FQHCs.

Bi-State is a private, nonprofit 501(c)(3) charitable organization with a broad membership of thirty-three organizations in Vermont and New Hampshire that provide and/or support community-based primary care services. Bi-State works with federal, state, and regional health policy organizations and policymakers, foundations and payers to develop strategies, policies and programs that promote and sustain community-based, primary health care services.

For more information on the Recruitment Center contact Stephanie Pagliuca, Director, at [email protected].

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Vermont Primary Care Sourcebook

January 2015

Vermont Migrant Farmworkers: Partners working in collaboration to ensure access to health care

Counties Served: 2009-2012 2012-2015 2015-2018 116 farms/447 workers 145 farms/716 workers 202 farms/1,100 workers (proposed application in review)

Farmworkers have unique barriers to accessing care

• 1. Language 2. Lack of insurance 3. Cost of care 4. Transportation

• 5. No time to go to the doctor 6. Fear of leaving the farm

Care coordination in action

How can policymakers FQHCs support the project? UVM Bi-State Extension  Sustain medical infrastructure

 Sustain care coordination model Farmworkers

 Address barriers to care Open Door Hospitals Clinic

Other free clinics

For further information, contact Sharon Winn, Esq., MPH, Director of Vermont Public Policy: 229-0002, ext. 218 Increase Access Manage Cost Improve Quality 18

Vermont Primary Care Sourcebook

January 2015

Supporting Vermonters with Vermont Health Connect

Bi-State’s membership of Federally Qualified Health Centers, Rural Health Clinics, and Planned Parenthood of Northern New England has numerous certified Assistors, who, along with Bi- State’s three certified Navigators, assisted Vermonters with understanding their health coverage options and enrolling in a health plan. Assistors and Navigators provided extensive outreach, such as manning booths at local libraries, fairs, and festivals; holding flu vaccination clinics; and creating qualifying event packets for individuals in transition. Bi-State Navigators also provided technical assistance and support to fellow Assistors in the state.

As a partner in health reform, Bi-State’s goal was to help Vermonters gain health coverage, but also to provide other Navigators and Assistors around the state with the training, tools, resources, and collaboration necessary to do their jobs well.

Navigators also:

Provided 8 regional Peer-to-Peer events for Assistors around Vermont

Organized and held Enrollment Events

Provided a webinar to Assistors statewide on how various income types are counted under the Modified Adjusted Gross Income rules.

Created a highly utilized forum for Assistors statewide to collaborate, communicate, share best practices, and timely information

Created tools and templates to be used by Assistors for outreach and enrollment

Sent out monthly VHC updates to over 400 Assistors and Community Partners

Attended monthly Medicaid & Exchange Advisory Board meetings, disseminating the information from the meetings to Assistors and other stakeholders Collaborated with VHC to create an educational video for health centers and other organizations to use in their waiting rooms and/or on their websites, reaching more than 8,000 people

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Vermont Primary Care Sourcebook

January 2015

Telehealth in Rural Areas: Clinical, Educational, and Networking Collaborations

What is telehealth? The Health Resources Services Administration (HRSA) defines telehealth as the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. The American Telemedicine Association provides examples of available telehealth services, including: patient consultations via video conferencing, transmission of still images, e- health including patient portals, remote monitoring of vital signs, continuing medical education, and consumer- focused wireless applications and nursing call centers, among other applications.

The VRHA Telehealth Network Bi-State, through the Vermont Rural Health Alliance (VRHA), received a four-year grant from the Office for Advancement in Telehealth, Office of Rural Health Policy DHHS, to support Vermont’s FQHCs in building a model for sharing clinical resources through telemedicine. The FQHCs started with management of obesity, and include Registered Dietician and diabetes patient consultations, peer-peer support, and a framework for sharing and adopting protocols and guidelines. VRHA is currently identifying additional local needs and developing plans for future service offerings.

Clinical Telemedicine Services Currently Offered to Patients at FQHCs In the past year, patients have saved approximately  Child & Adolescent Psychiatry 5,920 miles of travel by having virtual access to  Adult Psychiatry these services at their local FQHC rather than  Nutrition Education driving to see a specialist in person.  Diabetes Education

Education and Networking Opportunities Bi-State and its members frequently utilize teleconferencing equipment and software to hold administrative and peer- to-peer networking meetings, allowing for more frequent gatherings of individuals from across the state, while simultaneously decreasing travel costs. Through a collaboration with Vermont Care Partners, Bi-State initiated a series of educational sessions entitled “Learning Locally” that has been broadcast to the FQHCs, hospitals, and Community Mental Health Centers using telemedicine equipment. The Learning Locally schedule can be found at: www.bistatepca.org/telehealth.

Remote Telemonitoring for Management of Chronic Diseases: Bi-State’s and Community Health Accountable Care (CHAC) are working to implement a remote telemonitoring program for Medicare beneficiaries with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and diabetes. This program engages patients in their care through telephone or internet technologies that report their vital signs and symptoms on a daily basis. This, in turn, will allow the patient’s care team to identify and prevent any negative trends early, thereby reducing visits to the emergency room and hospital admissions.

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Vermont Primary Care Sourcebook

January 2015

Increase Access

Improve Quality Manage

Cost

Health centers manage costs by:

Providing comprehensive and integrated primary care

Participating in statewide payment reform activities, including Accountable Care Shared Savings Programs. Utilizing capped encounter-based Medicare & Medicaid reimbursement (FQHCs & RHCs) Effectively managing the care of patients with disproportionately high prevalance of chronic conditions and co-morbidities

Working with community partners to avert costly hospital admissions

Outreach to uninsured patients who would be less likely to delay seeking medical care or to seek care in the Emergency Room, if they had a medical home

Engaging in Emergency Department diversion

Offering favorable 340B federal drug pricing program

Utilizing Federal Tort Claims Act (FTCA) malpractice coverage (FQHCs)

Leveraging federal funds to help pay for infrastructure and workforce.

21 Manage Cost Vermont Primary Care Sourcebook

January 2015

Community Health Accountable Care, LLC

Community Health Accountable Care, LLC (CHAC) is a primary care-centric Accountable Care Organization (ACO). CHAC’s mission is to achieve the three part aim of better care for individuals, better health for populations, and lower growth in expenditures in connection with both public and private payment systems.

CHAC’s Network and Partners: Number of Product Attributed Lives*  11 Federally Qualified Health Centers

 5 Hospitals Medicare 6,400  15 Community Mental Health Centers and Developmental Services Agencies  10 Home Health Agencies Medicaid 26,500

 Bi-State Primary Care Association Commercial 8,900

Attributed Lives

21% 15% Medicare

Medicaid

Commercial

64%

* Attribution is fluid, changing from month to month. Approximations are based upon the best known information as of November 2014 and includes attributed lives from nine of CHAC’s 11 FQHC participants.

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Vermont Primary Care Sourcebook

January 2015

Studies Demonstrate Federally Qualified Health Centers Manage Costs

FQHCs Reduce Hospital Admissions

A Colorado study1 compared claims data of Medicaid patients with two or more primary care visits in one year at FQHC and non-FQHC settings: • The odds of a Medicaid FQHC patient being admitted to the hospital were 32% less likely than for a Medicaid non-FQHC patient; • The odds of an FQHC patient being readmitted 90 days after discharge were 35% less likely; • The odds of an FQHC patient being admitted for a primary care preventable condition were 36% less likely.

FQHCs Save Money

A comparison of costs for FQHC and non-FQHC patients demonstrates FQHC savings of $1,263 per person per year in hospital emergency department, hospital inpatient, ambulatory, and other services ($4,043 vs. $5,306). 2

FQHCs Reduce Utilization of Hospital Services

A review of 1.6 million Medicaid beneficiaries in four states3 showed that FQHC Medicaid patients compared to other providers: • had 1/3 fewer Ambulatory Care Sensitive (ACS) hospitalizations; • were 19% less likely to use the Emergency Department for an ACS condition, and; • were 11% less likely to be hospitalized for an ACS condition.

1 Rothkopf, J, Brookler K, Wadhwa, S, Sajovetz, M. “Medicaid Patients Seen At Federally Qualified Health Centers Use Hospital Services Less than Those Seen By Private Providers.” Health Affairs 30, No. 7 (2011): 1335-1342. 2 Ku L, et al. Using Primary Care to Bend the Curve: Estimating the Impact of a Health Center Expansion in Senate Reforms. GWU Department of Health Policy. Policy Research Brief No. 14, September 2009. 3 Falik M, Needleman J, Herbert R, et al. “Comparative Effectiveness of Health Centers as Regular Source of Care.” January- March 2006 Journal of Ambulatory Care Management 29(1): 24-35.

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Manage Cost

Vermont Primary Care Sourcebook January 2015 Federally Qualified Health Centers Benefit the State & their Communities

• Federally Qualified Health Centers (FQHCs) receive federal grants that allow them to offer a sliding fee scale to help patients pay for care and to invest in medical, oral health, behavioral health, and enabling services. • FQHCs receive from Medicaid and Medicare a prospectively set consistent payment for each patient encounter. • FQHC providers are covered through the Federal Tort Claims Act (FTCA) for professional liability. • FQHCs are automatically eligible for National Health Service Corps (NHSC) loan repayments and scholarship recipients, but receiving the benefit of eligibility is a competitive process through HRSA. • FQHCs participate in the 340B Pharmacy Program and pass savings along to patients and Medicaid. FQHCs and Collaboration FQHCs to collaborate with other health care and social services organizations in their communities to strengthen the health system as a whole. For example, FQHCs partner with…

• on emergency room diversion, transitions in care, Hospitals and other quality initiatives.

Free clinics • to provide outreach to uninsured Vermonters.

Community Mental • on behavioral health integration (including through Health Centers telemedicine).

The Vermont Department • on public health initiatives. of Health

Universities, colleges, • on medical student education, workforce pipeline technical schools, development, and telemedicine utilization. and high schools

• to offer a 340B Pharmacy Network, a pediatric Other FQHCs mobile dental program, and other services to meet community care needs.

24 Increase Access Manage Cost Improve Quality

Vermont Primary Care Sourcebook January 2015

Federally Qualified Health Center Funding and Reimbursement Structure Minimizes Cost Shifting • FQHCs are eligible to receive federal appropriations for allowable costs that are not reimbursed by Medicaid, Medicare, commercial payers, and patient self-pay. Some of these costs may include care provided to uninsured and underinsured low-income patients and enabling services such as care management, outreach, transportation, interpretation. • Federal FQHC grants are awarded based upon a very competitive national application process. • When FQHCs are awarded federal funds, they must meet strict program, performance, and accountability standards. • Federal FQHC appropriations are not transferable to any other entity. • Medicare and Medicaid FQHC reimbursement can be described as a prospective, capped encounter rate based upon Medicare allowable costs. • FQHCs bill commercial insurers just like any other primary care practice. • No payer – Medicaid, Medicare, or commercial insurance—reimburses FQHCs for their full costs.

2013 Sources of Revenue for Vermont FQHCs1

Other Grants 2% State Grant Other Revenue 2% 13% Patient Revenue: Federal Grant: Medicaid Capital 27% 1%

Federal Grant: Operating 11%

Patient Revenue: Patient Revenue: Medicare Commercial/ 13% Other Public 21% Patient Revenue: Uninsured/ Self Pay 10%

1Excludes data for Gifford Health Care; data for Battenkill Valley Health Center and Mountain Health Center is self- reported

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Vermont Primary Care Sourcebook

January 2014

Increase

Access

Manage Improve Cost

Quality

Health centers improve quality by:

Demonstrating strong clinical outcomes, even for the most acute primary care patients

Achieving NCQA Patient-Centered Medical Home recognition

Participating in the Vermont Blueprint for Health

Utilizing Electronic Health Records

Participating in Health Information Exchange

Performing real-time panel management

Conducting Quality Improvement

Learning best practices from each other

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Vermont Primary Care Sourcebook

January 2015

Vermont Health Centers Recognized as Patient Centered Medical Homes (PCMH) by the National Committee for Quality Assurance (NCQA)

Sites Awarded Sites to be Health Center Name Recognition by Scored NCQA PCMH Battenkill Valley Health Center (FQHC) 1

Community Health Centers of Burlington (FQHC) 1

Community Health Centers of the Rutland Region (FQHC) 6

Community Health Services of Lamoille Valley (FQHC) 2 1

Gifford Health Care (FQHC) 5

The Health Center (FQHC) 1

Little Rivers Health Care (FQHC) 3

Mountain Health Center (FQHC) 1

Newport Pediatrics and Adolescent Medicine (RHC) 1

North Country Health Systems (RHC) 4

Northern Counties Health Care (FQHC) 5

Northern Tier Center for Health (FQHC) 5

Springfield Medical Care Systems (FQHC) 5

Totals: 43 1

As of January 2014, 100% of Vermont Federally Qualified Health Centers (FQHCs) and Bi-State member Rural Health Clinics (RHCs) have been recognized by the National Committee for Quality Assurance (NCQA) as Patient Centered Medical Homes (PCMH), compared to 40.5% of FQHCs nationally.*

* BPHC/HRSA Web site Health Center 2012 Program Data: http://bphc.hrsa.gov/uds/datacenter.aspx?year=2012

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Vermont Primary Care Sourcebook

January 2015

Vermont Health Centers with Fully Implemented Electronic Health Records (EHR) and Attesting for Meaningful Use (MU)

Medical Sites Medical Sites Health Center Name Attested to EHR In Process MU A/I/U*

Battenkill Valley Health Center (FQHC) 1 eClinicalWorks

Community Health Centers of Burlington (FQHC) 2 NextGen

Community Health Centers of the Rutland Region Allscripts / 6 (FQHC) eClinicalWorks

Community Health Services of Lamoille Valley (FQHC) 5 eClinicalWorks

Gifford Health Care (FQHC) 6 CPSI

The Health Center (FQHC) 1 GECentricity

Little Rivers Health Care (FQHC) 3 eClinicalWorks

Mountain Health Center (FQHC) 1 Amazing Charts

Physician’s Newport Pediatrics and Adolescent Medicine (RHC) 1 Computer Company

North Country Health Systems (RHC) 5 Allscripts

*Original attestation Northern Counties Health Care (FQHC) 5 with Practice Partners – moving to GECentricity

Northern Tier Center for Health (FQHC) 5 GECentricity

Planned Parenthood of Northern New England 8 NextGen

Springfield Medical Care Systems (FQHC) 5 Allscripts

91% of Vermont Federally Qualified Health Centers (FQHCs), Bi-State member Rural Health Clinics (RHCs), and Planned Parenthood of Northern New England have fully implemented EHRs. Fifty-seven sites are attesting for meaningful use.

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Vermont Primary Care Sourcebook

January 2015

FQHC Youth Programs

• Offers medical provider outreach to family shelters Community Health • School-based medical and dental programs Centers of • Runs the Pearl Street Youth Health Center Burlington • Holds "Mother and Child" clinics with social work support • Offers the “Reach Out and Read” pediatric literacy program

Community • Offers job shadowing for students Health Centers of the Rutland • Holds family focus groups on Asthma education • Holds health fairs that cover multiple ages and education areas Region

• Offers "Co-Ed Youth Empowerment" program to help teens develop life skills Community • Promotes the "Reach Out and Read" literacy program Health • Offers "7 Challenges," a school-based substance abuse program • Offers "Voices" group for self-discovery and empowerment for females Services of ages 12-15 Lamoille • Provides free car seat inspections Valley • Offers “Youth in Transition” program: for young adults age 16 to 21 at risk for dropping out of school or becoming incarcerated • School-based psychiatry

• Parent support group (covers breast feeding, growth and developement, etc.)

• Infant/toddler support group Gifford Health • Infant CPR classes in conjunction with WRVA Care • Babysitting classes, After School Program for kids • Volunteer and Observational opportunities for High School and Junior High School kids

• Provides the school nurse for Cabot Elementary School • The "Ronald McDonald Care Mobile" is a collaborative effort between 5 Vermont FQHCs to provide access to dental services for children The Health • Offers “Nurturing Parenting” classes that educates parents on how to Center deal with difficult behaviors and establish positive relationships with their children • Offers student training opportunities for college and high school students • Offers child and family counseling via telemedicine

Increase Access 29

• Participates in HRSA’s "Text 4 Baby" program which is a free service that uses text messages to send new and expecting mothers tips on how to have a healthy pregnancy and caring for their infant • Offers job shadow opportunities for students Little Rivers • Provides adolescent depression screening project in conjunction with Health Care Dartmouth Medical Center • Offers “Rocking Horse Circle of Support" group: a program for mothers whose lives are touched in some way by substance abuse • Participates in the "Ronald McDonald Care Mobile" program

• Offers adolescent depression screening • Coordinates with school-based nutrition specialists to create community- Mountain based cooking classes for children Health Center • Offers job shadowing for students • Coordnates with school-based medical and behavioral health programs • Supports the "Reach Out and Read" literacy program

• Provides maternal and child health services that include well child checkups and pre-natal visits • Supports the "Reach Out and Read" literacy program • Provides school-based dental hygiene education Northern • Participates in "Bright Futures" program, promoting iniatives to support Counties healthy children and their families Health Care • Provides nursing support including education, assessment, and resource development for Medicaid-eligible pregnant women and their children • Nurse home visitors help low-income women pregnant withtheir first child to achieve healthier pregnancies and births, stronger child development, and a path toward economic self-sufficiency • Runs the Richford Day Camp, a free summer camp for 200+ children • Delivers “Tooth Tutor” program in local schools • Provides space at NoTCH Partnering Project for various agencies that Northern Tier serve youth and families Center for • Offers “Nurturing Parenting” classes that focus on educating parents how Health to deal with difficult behaviors and establish positive relationships with their children • Offers training opportunities for high school and college students pursuing careers in healthcare

• Offers cooking classes for children and families • Offers “Sibling Class” which educates families expecting another child on Springfield how to adjust to a new baby in the family Medical Care • Provides childcare services: operates two day cares that serve both Systems employees and the community • Some of the services listed can be attributed to Springfield Hospital, with whom SMCS is affiliated.

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Vermont Primary Care Sourcebook

January 2015 FQHC Federal Requirements Defined Federally Qualified Health Centers (FQHCs) are health care practices that have a mission to provide high quality, comprehensive primary care and preventive services regardless of their patients' ability to pay or insurance coverage. FQHCs must successfully compete in a national competition for FQHC designation and funding. Additionally, they must be located in federally-designated medically underserved areas and/or serve federally-designated medically underserved populations.

Per Federal Requirements, FQHCs must: 1. Demonstrate and document the needs of their target populations, updating their service areas, when appropriate. 2. Provide all required primary, preventive, enabling health services and additional health services as appropriate and necessary, either directly or through established written arrangements and referrals. 3. Maintain a core staff as necessary to carry out all required primary, preventive, enabling, and additional health services as appropriate and necessary, either directly or through established arrangements and referrals. Staff must be appropriately credentialed and licensed. 4. Provide services at times and locations that assure accessibility and meet the needs of the population to be served. 5. Provide professional coverage during hours when the health center is closed. 6. Ensure their physicians have admitting privileges at one or more referral hospitals, or other such arrangement to ensure continuity of care. In cases where hospital arrangements (including admitting privileges and membership) are not possible, health centers must firmly establish arrangements for hospitalization, discharge planning, and patient tracking. 7. Have a system in place to determine eligibility for patient discounts adjusted on the basis of the patient’s ability to pay. No patient will be denied services based on an inability to pay. 8. Have an ongoing Quality Improvement/Quality Assurance (QI/QA) program that includes clinical services and management, and maintains the confidentiality of patient records. 9. Maintain a fully staffed management team as appropriate for the size and needs of the center. 10. Exercise appropriate oversight and authority over all contracted services, including assuring that any subrecipient(s) meets Health Center Program Requirements. 11. Make efforts to establish and maintain collaborative relationships with other health care providers, including other health centers in the service area of the health center. 12. Maintain accounting and internal control systems appropriate to the size and complexity of the organization to safeguard assets and maintain financial stability. 13. Have systems in place to maximize collections and reimbursement for costs in providing health services, including written billing, credit, and collection policies and procedures. 14. Develop annual budgets that reflect the cost of operations, expenses, and revenues (including the federal grant) necessary to accomplish the service delivery plans. 15. Have systems which accurately collect and organize data for program reporting and which support management decision-making. 16. Maintain their funded scope of project (sites, services, service area, target population, and providers). 17. Ensure governing boards maintain appropriate authority to oversee operations. 18. Ensure a majority of board members for each health center are patients of the health center. The board, as a whole, must represent the individuals being served by the health center in terms of demographic factors such as race, ethnicity, and sex. 19. Ensure bylaws and/or policies are in place that prohibit conflict of interest by board members, employees, consultants, and those who furnish goods or services to the health center. Source: Summary of Health Center Program Requirements. (July 2011). Bureau of Primary Health Care, Health Resources and Services Administration. http://bphc.hrsa.gov/about/requirements/hcpreqs.pdf

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Vermont Primary Care Sourcebook

January 2015

Federally Qualified Health Centers Ensure Access in their Communities

Federally Qualified Health Centers (FQHCs) offer services to all residents of their service areas and determine charges using a sliding fee scale, which is based upon the resident’s ability to pay.

In many communities, FQHCs are the only provider open to new patients without restrictions, especially uninsured and Medicaid patients (statewide, 72% of primary care physicians accept new Medicaid patients1).

Vermont FQHCs provide care to 1 in 4 Vermonters,2, 3

including more than:

1 in 3 Vermont Medicaid enrollees

1 in 4 Vermont Medicare enrollees

1 in 5 commercially insured Vermonters

1 2010 VT Physician Survey, Summary Report. 2 FQHC data from UDS 2013 Vermont Roll-up; Statewide data from 2012 DFR Vermont Household Health Insurance Survey. 3 FQHCs provide care to 1 in 3 uninsured Vermonters when comparing 2013 FQHC data to 2012 DFR Vermont Household Health Insurance Survey data. Given the significant drop in uninsured Vermonters noted in the 2014 DFR Vermont Household Health Insurance Survey, we are not able with current data to accurately state the number of uninsured Vermonters receiving care at FQHCs.

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Vermont Primary Care Sourcebook January 2015

Federally Qualified Health Centers Provided Primary Care to 153,000+ Vermonters in 2013

Vermont’s 11 FQHCs saw 153,280 individual patients in 2013. Collectively, those patients made 618,041 visits to the FQHCs.1 From 2011 through 2013, Vermont FQHCs served as a medical home for more than 196,000 Vermonters.2

FQHC Patients by Payer in 2013 Types of Health Insurance in Vermont 20143

Uninsured Uninsured 4%

7% 23,231 11,120

Medicare

19% Medicaid 28,940 21% 132,829

Third Party Medicaid 46% Medicare 28% Third Party 70,341 18% 42,827 57% 110,916 359,655

Poverty Level Status of FQHC Patients

The incentive to report FPL status is to access the sliding fee scale. Patients who do not report likely >200% poverty level (21%) have full coverage through Medicaid, or high enough FPL they <200% poverty level (49%) would not qualify for assistance.

Unknown (30%) Patients at <200% poverty level represent 30%-69% of patient mix across FQHCs. FQHCs at the lower end of this range are sole (or nearly sole) community providers.

1 Data is self-reported by FQHC. 2Bi-State extrapolation based on self-reported data. 3Data Source: 2014 Vermont Household Health Insurance Survey

Increase Access Manage Cost Improve Quality 33

Vermont Primary Care Sourcebook January 2015 What is the FQHC Sliding Fee Scale?

Federally Qualified Health Centers (FQHCs) that receive Health Resources and Services Administration (HRSA) funding must provide patients access to services without regard for their patient's ability to pay.

FQHCs must develop a schedule of fees or payments (often called a sliding fee scale) for the services they provide to ensure that the cost of services not covered by insurance are discounted on the basis of the patient's ability to pay, for incomes below 200% of the Federal Poverty Level (FPL). Ability to pay is determined by a patient's annual income and family size according to the most recent U.S. Department of Health & Human Services Federal Poverty Guidelines.

SAMPLE Vermont FQHC Sliding Fee Scale1 Annual Family Income Range Household Below 100% 101 – 125% 126 – 150% 151 – 175% 176 – 200% Over 200% Size FPL FPL FPL FPL FPL FPL Discount 80% 20% $20 flat fee 60% discount 40% discount 0% discount Applied discount discount Under $11,671 – $14,589 – $17,506 – $20,424 – 1 Over $23,341 $11,670 14,588 17,505 20,423 23,340 Under $15,731 – $19,664 – $23,596 – $27,529 – 2 Over $31,461 $15,730 119,663 23,595 27,528 31,460 Under $19,791 – $24,739 – $29,686 – $34,634 – 3 Over $39,581 $19,790 24,738 29,685 34,633 39,580

Under $23,851 – $29,814– $35,776 – $41,739– 4 Over $47,701 $23,850 29,813 35,775 41,738 47,700 Under $27,911 – $34,889 – $41,866 – $48,844– 5 Over $55,821 $27,910 34,888 41,865 48,843 55,820 Under $31,971 – $39,964 – $47,956 – $55,949 – 6 Over $63,941 $31,970 39,963 47,955 55,948 63,940 Under $36,031– $45,039 – $54,046 – $63,054 – 7 Over $72,061 $36,030 45,038 54,045 63,053 72,060 Under $40.091 – $50,114 – $60,136 – $70,159 – 8 Over $80,181 $40,090 50,113 60,135 70,158 80,180 Additional Add $4,060 Add $5,075 Add $6,090 per Add $7,105 Add $8,120 Add $8,120 people per person per person person per person per person per person

2 Vermont FQHC discounts exceeded $3 million in 2013.

To ensure that federal funding targets those who most need services, FQHCs have systems in place to maximize collection and reimbursement for the costs of providing health services.

Vermont FQHCs wrote off $2,353,737 in bad debt in 2013.

1 Sliding Fee Scale. Health Resources and Services Administration, http://nhsc.hrsa.gov/downloads/discountfeeschedule.pdf, accessed 12/22/2014. 2 Bi-State Primary Care Association FQHC Financial Analysis, July 2014. Data is for 8 of the 11 Vermont FQHCs.

Increase Access Manage Cost 34 Vermont Primary Care Sourcebook

January 2015

Bi-State Primary Care Association Vermont Member Legislative Representation List by Legislator 2015-2016 Biennium

Rep. Janet Ancel (D) Washington-6 Rep. Steven Berry (D) Bennington-4 Health Center: Health Center: 1. The Health Center 1. Battenkill Valley Health Center

Sen. Tim Ashe (D/P) Chittenden District Rep. Steve Beyor (R) Franklin-5 Health Center: Health Center: 1. Community Health Centers of Burlington 1. Northern Tier Center for Health

Sen. Claire Ayer (D) Addison District Rep. Clem Bissonnette (D) Chittenden-6-7 Health Centers: Health Center: 1. Community Health Centers of the Rutland 1. Community Health Centers of Burlington Region 2. Mountain Health Center Rep. Bill Botzow (D) Bennington-1 Health Center: Sen. Becca Balint (D) Windham District 1. Battenkill Valley Health Center Health Center: 1. Springfield Medical Care Systems, Inc. Rep. Carolyn Whitney Branagan (R) Franklin-1 Health Center: Rep. Robert Bancroft (R) Chittenden-8-3 1. Northern Tier Center for Health Health Center: 1. Community Health Centers of Burlington Sen. Christopher Bray (D) Addison District Health Centers: Sen. Phillip Baruth (D) Chittenden District 1. Community Health Centers of the Rutland Health Center: Region 1. Community Health Centers of Burlington 2. Mountain Health Center

Rep. Fred Baser (R) Addison-4 Rep. Patrick Brennan (R) Chittenden-9-2 Health Centers: Health Center: 1. Mountain Health Center 1. Community Health Centers of Burlington

Rep. Lynn Batchelor (R) Orleans-1 Rep. Timothy Briglin (D) Windsor-Orange-2 Health Centers: Health Center: 1. Newport Pediatrics and Adolescent 1. Gifford Health Care Medicine 2. Northern Counties Health Care Rep. Cynthia Browning (D) Bennington-4 3. North Country Health Systems Health Center: 1. Battenkill Valley Health Center Rep. Scott Beck (R) Caledonia-3 Health Center: Rep. Tom Burditt (R) Rutland-2 1. Northern Counties Health Care Health Center: 1. Community Health Centers of the Rutland Sen. Joe Benning (R) Caledonia District Region Health Centers: 1. Little Rivers Health Care Rep. Sarah E. Buxton (D) Windsor-Orange-1 2. Northern Counties Health Care Health Center: 1. Gifford Health Care

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Vermont Primary Care Sourcebook

January 2015

Sen. John F. Campbell (D) Windsor District Sen. Ann Cummings (D) Washington District Closest health center is Springfield Medical Care Systems, Health Center: Inc. 1. The Health Center

Sen. Brian Campion (D) Bennington District Rep. Larry Cupoli (R) Rutland-5-2 Health Center: Health Center: Battenkill Valley Health Center 1. Community Health Centers of the Rutland Region Rep. Bill Canfield (R) Rutland-3 Health Center: Rep. Leigh Dakin (D) Windsor 3-1 1. Community Health Centers of the Rutland Health Center: Region 1. Springfield Medical Care Systems, Inc.

Rep. Steve Carr (D) Rutland-6 Rep. Maureen Dakin (D) Chittenden-9-2 Health Center: Health Center: 1. Community Health Centers of the Rutland 1. Community Health Centers of Burlington Region Rep. Paul Dame (R) Chittenden-8-2 Rep. Robin Chesnut-Tangerman (P) Rutland- Health Center: Bennington 1. Community Health Centers of Burlington Health Center: 1. Community Health Centers of the Rutland Rep. Susan Davis (P) Orange-1 Region Health Centers: 1. Gifford Health Care Rep. Joanna Cole (D) Chittenden-6-1 2. Little Rivers Health Care Health Center: 1. Community Health Centers of Burlington Rep. David L. Deen (D) Windham-4 Health Center: Sen. Brian Collamore (R) Rutland District 1. Springfield Medical Care Systems, Inc. Health Center: 1. Community Health Centers of the Rutland Sen. Dustin Degree (R) Franklin District Region Health Center: 1. Northern Tier Center for Health Rep. Jim Condon (D) Chittenden-9-1 Health Center: Rep. Dennis J. Devereux (R) Rutland- 1. Community Health Centers of Burlington Windsor-2 Health Center: Rep. Dan Connor (D) Franklin-6 1. Community Health Centers of the Rutland Health Center: Region 1. Northern Tier Center for Health 2. Springfield Medical Care Systems, Inc.

Rep. Chip Conquest (D) Orange-Caledonia Rep. Eileen “Lynn” Dickinson (R) Franklin-3-2 Health Centers: Health Center: 1. Little Rivers Health Care 1. Northern Tier Center for Health 2. Northern Counties Health Care Rep. Anne B. Donahue (R) Washington-1 Rep. Sarah Copeland-Hanzas (D) Orange-2 Health Center: Health Center: 1. The Health Center 1. Little Rivers Health Care Rep. Johannah Leddy Donovan (D) Rep. Timothy R. Corcoran (D) Bennington-2-1 Chittenden-6-5 Health Center: Health Center: 1. Battenkill Valley Health Center 1. Community Health Centers of Burlington

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Vermont Primary Care Sourcebook

January 2015

Sen. Bill Doyle (R) Washington District Rep. Marianna Gamache (R) Franklin-4 Health Center: Health Center: 1. The Health Center 1. Northern Tier Center for Health

Rep. Rebecca Ellis (D) Washington- Rep. Diana Gonzalez (P) Chittenden-6-7 Chittenden Health Center: Health Centers: 1. Community Health Centers of Burlington 1. Community Health Centers of Burlington 2. The Health Center Rep. Maxine Jo Grad (D) Washington-7 Health Center: Rep. Alice M. Emmons (D) Windsor 3-2 1. The Health Center Health Center: 1. Springfield Medical Care Systems, Inc. Rep. Rodney Graham (R) Orange-1 Health Centers: Rep. Debbie Evans (D) Chittenden-8-1 1. Little Rivers Health Care Health Center: 2. Gifford Health Care 1. Community Health Centers of Burlington Rep. Adam Greshin (I) Washington-7 Rep. Peter J. Fagan (R) Rutland-5-1 Health Center: Health Center: 1. The Health Center 1. Community Health Centers of the Rutland Region Rep. Sandy Haas (P) Windsor-Rutland Health Center: Rep. Marty Feltus (R) Caledonia-4 1. Gifford Health Care Health Center: 1. Northern Counties Health Care Rep. Helen Head (D) Chittenden-7-3 Health Center: Rep. Larry Fiske (R) Franklin-7 1. Community Health Centers of Burlington Health Center: 1. Northern Tier Center for Health Rep. Bob Helm (R) Rutland-3 Health Center: Sen. Peg Flory (R) Rutland District 1. Community Health Centers of the Rutland Health Center: Region 1. Community Health Services of Lamoille Valley Rep. Mark Higley (R) Orleans-Lamoille Health Center: Rep. Robert Forguites (D) Windsor-3-2 1. Community Health Services of Lamoille Health Center: Valley 1. Springfield Medical Care Systems, Inc. Rep. Mary S. Hooper (D) Washington-4 Rep. Bill Frank (D) Chittenden-3 Health Center: Health Center: 1. The Health Center 1. Community Health Centers of Burlington Rep. Ronald E. Hubert (R) Chittenden-10 Rep. Patsy French (D) Orange-Washington- Health Center: Addison 1. Community Health Centers of Burlington Health Center: 1. Gifford Health Care Rep. Mark Huntley (D) Windsor -2 Health Center: Rep. Doug Gage (R) Rutland-5-4 1. Springfield Medical Care Systems, Inc. Health Center: 1. Community Health Centers of the Rutland Rep. Tim Jerman (D) Chittenden-8-2 Region Health Center: 1. Community Health Centers of Burlington

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Vermont Primary Care Sourcebook

January 2015

Rep. Willem Jewett (D) Addison-2 Rep. Paul Lefebvre (R) Essex-Caledonia- Health Center: Orleans 1. Community Health Centers of the Rutland Health Centers: Region 1. Northern Counties Health Care 2. North Country Health Systems Rep. Mitzi Johnson (D) Grand Isle-Chittenden 3. Newport Pediatrics and Adolescent Health Centers: Medicine 1. Community Health Centers of Burlington 2. Northern Tier Center for Health Rep. Joan G. Lenes (D) Chittenden-5-2 Health Center: Rep. Bernie Juskiewicz (R) Lamoille-3 1. Community Health Centers of Burlington Health Center: 1. Community Health Services of Lamoille Rep. Patti J. Lewis (R) Washington-1 Valley Health Center: 1. The Health Center Rep. Kathleen C. Keenan (D) Franklin-3-1 Health Center: Rep. William J. Lippert (D) Chittenden-4-2 1. Northern Tier Center for Health Health Center: 1. Community Health Centers of Burlington Sen. Jane Kitchel (D) Caledonia District Health Centers: Sen. Virginia “Ginny” Lyons (D) Chittenden 1. Little Rivers Health Care District 2. Northern Counties Health Care Health Center: 1. Community Health Centers of Burlington Rep. Warren F. Kitzmiller (D) Washington-4 Health Center: Rep. Terry Macaig (D) Chittenden-2 1. The Health Center Health Center: 1. Community Health Centers of Burlington Rep. Tony Klein (D) Washington-5 Health Center: Sen. Mark A. MacDonald (D) Orange District 1. The Health Center Health Centers: 1. Gifford Health Care Rep. Bob Krebs (D) Grand Isle-Chittenden 2. Little Rivers Health Care Health Centers: 1. Community Health Centers of Burlington Rep. Michael Marcotte (R) Orleans-2 2. Northern Tier Center for Health Health Centers: 1. Newport Pediatrics and Adolescent Rep. Jill Krowinski (D) Chittenden-6-3 Medicine Health Center: 2. North Country Health Systems 1. Community Health Centers of Burlington Rep. Marcia Martel (R) Caledonia-1 Rep. Martin LaLonde (D) Chittenden 7-1 Health Center: Health Center: 1. Little Rivers Health Care 1. Community Health Centers of Burlington 2. Northern Counties Health Care

Rep. Richard Lawrence (R) Caledonia-4 Rep. Linda J. Martin (D) Lamoille-2 Health Center: Health Centers: 1. Northern Counties Health Care 1. Community Health Services of Lamoille Valley 2. Northern Counties Health Care

Rep. Jim Masland (D) Windsor-Orange-2 Health Center: 1. Gifford Health Care

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Vermont Primary Care Sourcebook

January 2015

Sen. Dick Mazza (D) Grand Isle District Rep. Anne Theresa O’Brien (D) Chittenden-1 Health Centers: Health Center: 1. Community Health Centers of Burlington 1. Community Health Centers of Burlington 2. Northern Tier Center for Health Rep. Jean O’Sullivan (D) Chittenden-6-2 Sen. Norm McAllister (R) Franklin District Health Center: Health Center: 1. Community Health Centers of Burlington 1. Northern Tier Center for Health Rep. Oliver Olsen (I) Windham-Bennington- Sen. Dick McCormack (D) Windsor District Windsor Closest health center is Springfield Medical Care Systems, Health Centers: Inc. 1. Battenkill Valley Health Center 2. Springfield Medical Care Systems, Inc. Rep. Curt McCormack (D) Chittenden-6-3 Health Center: Rep. Corey Parent (R) Franklin-3-1 1. Community Health Centers of Burlington Health Center: 1. Northern Tier Center for Health Rep. Patricia McCoy (R) Rutland-1 Health Center: Rep. Carolyn W. Partridge (D) Windham-3 1. Community Health Centers of the Rutland Health Center: Region 1. Springfield Medical Care Systems, Inc.

Rep. Jim McCullough (D) Chittenden-2 Rep. Avram Patt (D) Lamoille-Washington Health Center: Health Center: 1. Community Health Centers of Burlington 1. Community Health Services of Lamoille Valley Rep. Alice Miller (D) Bennington-3 2. The Health Center Health Center: 1. Battenkill Valley Health Center Rep. Albert “Chuck” Pearce (R) Franklin-5 Health Center: Rep. Kiah Morris (D) Bennington 2-2 1. Northern Tier Center for Health Health Center: 1. Battenkill Valley Health Center Rep. Christopher Pearson (P) Chittenden-6-4 Health Center: Rep. Mary A. Morrissey (R) Bennington 2-2 1. Community Health Centers of Burlington Health Center: 1. Battenkill Valley Health Center Sen. Anthony Pollina (P/D) Washington District Rep. Michael Mrowicki (D) Windham-4 Health Centers: Health Center: 1. Gifford Health Care 1. Springfield Medical Care Systems, Inc. 2. The Health Center

Sen. Kevin Mullin (R) Rutland District Rep. Dave Potter (D) Rutland-2 Health Center: Health Center: 1. Community Health Centers of the Rutland 1. Community Health Centers of the Rutland Region Region

Rep. Linda K. Myers (R) Chittenden-8-1 Rep. Ann Pugh (D) Chittenden 7-2 Health Center: Health Center: 1. Community Health Centers of Burlington 1. Community Health Centers of Burlington

Sen. Alice W. Nitka (D) Windsor District Rep. Joey Purvis (R) Chittenden-9-1 Closest health center is Springfield Medical Care Systems, Health Center: Inc. 1. Community Health Centers of Burlington

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Vermont Primary Care Sourcebook

January 2015

Rep. Connie Quimby (R) Essex-Caledonia Rep. Loren Shaw (R) Orleans-1 Health Center: Health Centers: 1. Northern Counties Health Care 1. Newport Pediatrics and Adolescent Medicine Rep. Barbara Rachelson (D) Chittenden-6-6 2. Northern Counties Health Care Health Center: 3. North Country Health Systems 1. Community Health Centers of Burlington Sen. Michael Sirotkin (D) Chittenden District Rep. Kesha K. Ram (D) Chittenden-6-4 Health Center: Health Center: 1. Community Health Centers of Burlington 1. Community Health Centers of Burlington Rep. Shap Smith (D) Lamoille-Washington Sen. John Rodgers (D) Essex-Orleans District Health Centers: Health Centers: 1. Community Health Services of Lamoille 1. Newport Pediatrics and Adolescent Valley Medicine 2. The Health Center 2. Northern Counties Health Care 3. North Country Health Systems Sen. Diane Snelling (R) Chittenden District Health Center: Rep. Herb Russell (D) Rutland-5-3 1. Community Health Centers of Burlington Health Center: 1. Community Health Centers of the Rutland Sen. Robert Starr (D) Essex-Orleans District Region Health Centers: 1. Newport Pediatrics and Adolescent Rep. Marjorie Ryerson (D) Orange- Medicine Washington-Addison 2. Northern Counties Health Care Health Center: 3. North Country Health Systems 1. Gifford Health Care Rep. Tom Stevens (D) Washington- Rep. Brian K. Savage (R) Franklin-4 Chittenden Health Center: Health Centers: 1. Northern Tier Center for Health 1. Community Health Centers of Burlington 2. The Health Center Rep. Heidi E. Scheuermann (R) Lamoille-1 Health Center: Rep. Vicki Strong (R) Orleans-Caledonia 1. Community Health Services of Lamoille Health Centers: Valley 1. Newport Pediatrics and Adolescent Medicine Sen. Dick Sears (D) Bennington District 2. Northern Counties Health Care Health Center: 3. North Country Health Systems 1. Battenkill Valley Health Center Rep. Mary Sullivan (D) Chittenden-6-5 Rep. Dave Sharpe (D) Addison-4 Health Center: Health Center: 1. Community Health Centers of Burlington 1. Mountain Health Center Rep. Job Tate (R) Rutland-Windsor-1 Rep. Butch Shaw (R) Rutland-6 Health Center: Health Center: 1. Community Health Centers of the Rutland 1. Community Health Centers of the Rutland Region Region Rep. Thomas Terenzini (R) Rutland-4 Health Center: 1. Community Health Centers of the Rutland Region

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Vermont Primary Care Sourcebook

January 2015

Rep. George W. Till (D) Chittenden-3 Rep. Kurt Wright (R) Chittenden-6-1 Health Center: Health Center: 1. Community Health Centers of Burlington 1. Community Health Centers of Burlington

Rep. Kitty Beattie Toll (D) Caledonia- Rep. Mike Yantachka (D) Chittenden-4-1 Washington Health Center: Health Center: 1. Community Health Centers of Burlington 1. The Health Center 2. Northern Counties Health Care Rep. Sam Young (D) Orleans-Caledonia Health Centers: Rep. Maida Townsend (D) Chittenden 7-4 1. Newport Pediatrics and Adolescent Health Center: Medicine 1. Community Health Centers of Burlington 2. Northern Counties Health Care 3. North Country Health Systems Rep. Matthew Trieber (D) Windham-3 Health Center: Sen. David Zuckerman (P) Chittenden 1. Springfield Medical Care Systems, Inc. District Health Center: Rep. Chip Troiano (D) Caledonia-2 1. Community Health Centers of Burlington Health Center: 1. Northern Counties Health Care

Rep. Don Turner (R) Chittenden-10 Health Center: 1. Community Health Centers of Burlington

Rep. Gary Viens (R) Orleans-2 Health Centers: 1. Newport Pediatrics and Adolescent Medicine 2. North Country Health Systems

Rep. Kate Webb (D) Chittenden-5-1 Health Center: 1. Community Health Centers of Burlington

Sen. Richard Westman (R) Lamoille District Health Center: 1. Community Health Services of Lamoille Valley

Rep. Janssen Willhoit (R) Caledonia-3 Health Center: 1. Northern Counties Health Care

Sen. Jeanette K. White (D) Windham District Health Center: 1. Springfield Medical Care Systems, Inc.

Rep. Mark Woodward (D) Lamoille-2 Health Centers: 1. Community Health Services of Lamoille Valley 2. Northern Counties Health Care

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Vermont Primary Care Sourcebook

January 2015

Common Acronyms ACA Affordable Care Act (sometimes called PPACA, the Patient Protection and Affordable Care Act) ACO Accountable Care Organization AHEC Area Health Education Center ARRA American Recovery & Reinvestment Act BPHC Bureau of Primary Health Care CAH Critical Access Hospital CIP Capital Improvement Project CMS Centers for Medicare and Medicaid Services DFR Department of Financial Regulation (formerly BISHCA) DVHA Department of VT Health Access FIP Facility Investment Program FQHC Federally Qualified Health Center FTCA Federal Tort Claims Act GMCB Green Mountain Care Board HIE Health Information Exchange HIPAA Health Insurance Portability and Accountability Act HIT Health Information Technology HIX Health Insurance Exchange HPSA Health Professional Shortage Area HRSA Health Resources and Services Administration MSSP Medicare Shared Savings Program MU Meaningful Use MUA / MUP Medically Underserved Area / Medically Underserved Population NCQA National Committee for Quality Assurance ORHP Office of Rural Health Policy PCA Primary Care Association PCMH Patient Centered Medical Home (also called Advanced Medical Home, AMH) PCO Primary Care Office REC Regional Extension Center RHC Rural Health Clinic UDS Uniform Data Systems VCCU VT Coalition of Clinics for the Uninsured VCHIP Vermont Child Health Improvement Program VHC Vermont Health Connect VHCIP Vermont Health Care Innovation Project VHIE VT Health Information Exchange VITL VT Information Technology Leaders VPQHC VT Program for Quality in Health Care

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