What is VTBC?
Vermont Team-Based Care (VTBC) is a philosophy and set of individual and system-level practices to support people who have chronic health, mental health, substance use, and/or social needs. At its foundation, healthcare and human services organizations work together in partnership with the individual and/or family to identify needs, access appropriate resources and services, and support progress towards individual goals.
VTBC is not a new model– it was initially launched in 2015 as Complex Care and has been happening in communities across Vermont for years. Last year, the Agency of Human Services (AHS) worked with the Camden Coalition, with the help and feedback of many stakeholders, to assess where Vermont is in the adaptation and spread of this work. This year, we have the chance to expand and strengthen Complex Care, now called VTBC, through learning collaboratives and training opportunities.
VTBC Philosophy
The VTBC philosophy describes the way healthcare and human services are delivered for all Vermonters. It is trauma-responsive, person-centered, and requires teams to work across disciplines and sectors to support people with their medical, mental health, substance use, and social needs. At every entry point into the system of care, agency staff and providers screen for needs so that people can be connected to support if they wish. The goal is to be more proactive in care, help people reach their goals, and ensure Vermonters feel trust in the community.
VTBC Individual Practices
The VTBC individual practices include assessing biopsychosocial needs, helping identify goals, connecting to services and benefits, and supporting an individual’s desire to reach their goals. The intensity of care coordination in VTBC varies based on how much help someone needs and how complex their situation is. VTBC also includes collaborative practices among providers (lead care coordinator, shared care plan, case conferencing) to ensure that they are working as a team to achieve shared goals defined by the individual.
VTBC Systems Practices
The VTBC systems practices connect AHS and a vast array of organizations across the regional health and human services ecosystem.
Who is eligible for VTBC?
Team-based care serves a wide range of Vermonters who experience complex health and/or social needs. It's especially useful for those who need ongoing help from multiple providers or organizations. Each community decides who's eligible based on data, experience, and clinical knowledge.
How does VTBC fit into national trends?
VTBC is part of a national movement called complex care, which seeks to improve health and well-being for people with complex health and social needs by coordinating and reshaping care delivery at the individual, community, and system levels. Complex care addresses the root causes of poor health through interdisciplinary care teams and cross-sector partnerships that deliver person-centered care based around participants’ own goals and priorities. There is an increasing acknowledgment around the country of the importance of addressing social drivers of health for overall well-being.
In Massachusetts, it was shown that integrated and cross-organizational care teams are essential for high-quality care for people with complex health and social needs. Successful integrated care planning places the individual at the center of care by building