Network Spotlight: Vermont Care Network

May 2018
Vermont Care Network

Network Name Vermont Care Network
Location Montpelier, VT
Key Contact Simone Rueschemeyer, Executive Director
Mission To have a statewide network that integrates the full continuum of health, wellness and social services enabling Vermonters to lead full and satisfying lives. By providing care beyond health care and through enhanced services, collaboration and integration, we achieve improved value, health outcomes and life satisfaction.
Vision For all Vermonters to lead healthy and satisfying lives.

Simone Rueschemeyer, Executive Director of Vermont Care Network, was interviewed by the Network TA team to share information on the network’s characteristics, key learnings, accomplishments, and challenges.

Q: In a nutshell, how would you describe your network?

A: Our network is a statewide network of 16 community-based agencies serving people with mental health conditions, substance use disorders, and developmental disabilities. We partner with our sister agency, Vermont Council of Developmental and Mental Services, under the umbrella name of Vermont Care Partners. The Council is the advocacy and policy arm and the VCN is the business and innovation arm. The agencies serve approximately 32,000 clients, and touch the lives of about 50,000. Many of our agencies came to be as a result of the 1963 Community Mental Health Act, which was intended to move vulnerable individuals out of the institutions and back into productive and fulfilling lives in their communities. The network was originally formed in 1994 as a 501(c)(3) to respond to managed care coming into the state.

Then the organization laid dormant for a little while, until about 2005, when eight of the agencies came together again to respond to a Corrections RFP. At that time, they decided they needed to have a more formal structure, a more formal staffing pattern, bylaws, etc. Through the HRSA grant, they were able to hire a part-time executive director and really establish themselves. At that time, the network was the Behavioral Health Network of Vermont. The goal was to create effective partnerships and efficiencies to facilitate the provision of successful and high-quality care in the state, and to have a strategic return on investment by the network agencies, helping them to collaborate with stakeholders to work on systems integration, to find economies of scale, and to demonstrate to the state and to other stakeholders, that they were a high-quality, efficient network.

Q: What benefits do network members receive?

A: There are a number of benefits for the network. First and foremost is the ability to work together and share in best practice and innovation as well as sharing barriers to services delivery and solutions to those barriers. Our board is made up of the executive directors of each of the 16 agencies who meet monthly and retreat annually to strategize for the year. In addition, as part of our larger umbrella under Vermont Care Partners, we have monthly meetings where program directors from all of the agencies meet - crisis directors, CFOs, billing managers, compliance officers, IT managers, adult outpatient directors, children’s directors, outcomes and others. Those meetings were established in part to enable peers to share in barriers that they're facing, work through issues with the State or other stakeholders, discuss regulatory issues, share in best practice, and more.

In addition, we have a number of different initiatives where the network agencies come together. For example, we're working on health care and payment reform and are heavily invested in developing new value-based payment methodologies with the Departments of Mental Health and Disabilities, Aging and Independent Living. Our newly formed certification process – VCP Centers of Excellence - is informing those payment reform discussions and helping agencies to focus on quality improvement. We are also very focused on health information technology. I sit on the State’s HIE Steering Committee and am invested in ensuring that our network has the capabilities to share information within an integrated delivery system. We have secured grants to focus on improving data quality at the agencies and are developing a data repository so that they can conduct analytics at an individual agency level as well as at a network wide level. This is important for value demonstration, data sharing and improving the quality of care and delivery. In addition, nine of our agencies are looking to move to a new EMR. We have secured grants to assist them in that vetting process and are now focused on standardization of documents, reporting and workflows and enabling the agencies to become data driven organizations to fully participate in health and payment reform. We also have a focus on education and trainings. We hold a yearly conference and have two statewide training initiatives – Youth Mental Health First Aid and Team Two, a training for law enforcement and mental health crisis workers.

This network is about alleviating burdens so that member agencies can do the work that they were set out to do. They weren't set out, for example, to become experts in electronic medical records. Not every agency needs to have every expertise possible in order to make their agency function and thrive. We try to really think about what is it that we can do that can enable them to do their work better and what can we do to help move them forward to thrive in an ever-changing health delivery system.

Q: How have your network members built their trust and collaboration over the years?

A: We have made a point of creating an environment where people can truly speak with each other. “Let's just put things out there. Let's talk about the elephants in the room. Let's really work on establishing trust among the agencies.” Having open and honest communication is essential especially as we navigate through this web of health and payment reform, where a lot of it is uncertain and we know things are changing. It is also important in order to determine the direction we want, or need, to take. We know that we're going to be paid differently. We know that there aren't enough financial resources in our state and nationwide to be able to serve everybody in the way that we've been trying to serve them in the health delivery system at large. How does each agency function? How does each agency survive? How does each agency thrive in a new health care environment? And how do we do this together? We want to make sure that the people we are serving continue to be served in a high-quality manner in our communities. We want to ensure that our home and community based model of care is not only maintained but expanded. We keep stressing that there is power in numbers and that we are stronger together than we are as individual agencies. Collectively, the network serves 50,000 Vermonters. That is a powerful statement and motivates the group to work together to develop a cohesive message.

Building trust takes time. We have an incredible board of directors. Do we always agree? No. But I can't imagine what it would be like if we didn't have a board of directors that was as committed and involved. Due to our robust conversations, we understand what they need, what they are willing to support and where they want to head. We understand their frustrations. It's about communication. It's about being able to have some hard conversations. We were just talking about the development of a new project, and I said, "What would seem like success to you for the next six months in terms of this project?" One board member said, "If we're having really hard conversations, then that to me will be success." It's true. You can't sit around and “yes” each other all the time.

Q: How has your network approached sustainability?

A: Sustainability is always challenging for non-profits. Evaluating your programs is a key component of sustainability. We used to say, "If we don't all agree on moving something forward, we shouldn't do it." But we realized that striving for 100% participation in everything, won’t get us very far. If you have a majority of people who want to move forward or even a small group of people who want to move forward on something, that's fine. Try it. See if it works and then either make it really good so everybody else wants to join in or else recognize if it’s not working as well as anticipated.

If we start something that makes a lot of sense at the time but in the end, isn’t sustainable or isn’t having the outcomes that we were hoping it would have, it's okay to say, "You know what? That didn't work. We put a lot of time and energy into it, but it's not going to be fruitful for us in the long-term, so that's all right. What are the lessons learned? How do we move on? How do we take some of that into maybe a different model?" We haven't had to do that a lot, but it's really an essential part of moving forward when you're a nonprofit that is primarily grant-funded. You have to make sure initiatives are sustainable. You can't continuously rely on grants. We’re so unbelievably appreciative for the grants we receive, but we also have been very focused the last number of years on diversifying our revenue streams and creating consulting services or products that we can put out there.

Our partnership with the Vermont Council of Developmental and Mental Health Services is invaluable. We share an office, and much of our work overlaps in content. They work on behalf of the same 16 agencies, but they are a 501(c)(6), so they do all the policy and advocacy work. We focus on being the business and innovation arm. Together, we're a pretty strong force, and I feel our network has been able to be as successful as it has been because of our partnership with them as well as our extremely dedicated and involved board of directors and many of their staff who provide invaluable subject matter expertise. Sustainability is in part dependent on the value you provide and that is important to communicate. We can all always do a better job at demonstrating the value of our work.

Q: What challenges do you face working in rural health care?

A: While we push for an integrated delivery system in Vermont and nationwide, we haven't changed our financial structures enough to incentivize true integration and avoid competition. Some agencies are feeling that an integrated delivery system means merging organizations rather than keeping the expertise that you have and interweaving them. But it's hard to merge when you have different philosophies related to the provision of care. We feel strongly about having a trauma-informed, recovery oriented, home and community-based model of care delivery. We have a lot of conversations about what makes the most sense for the people that we serve, for individual agencies, and for the state as a whole.

One of our biggest struggles is recruitment and retention – in Vermont that is a problem statewide and seems to be more challenging the more we integrate with the larger delivery system. In addition, perception of what we do is a challenge. When you say you provide mental health services, people automatically think of a therapist's office. It's so much broader than that, and the same with our developmental disability and substance use programs. The breadth of our programming is tremendous. We have incredible employment programs, wellness programs, housing and housing stability. They help people engage in education, and they're also in the majority of the schools in our region. They work with law enforcement. They're embedded in police agencies. They're embedded in primary care practices. They're embedded in emergency rooms. They provide crisis services 24 hours a day, seven days a week.

Information technology is another huge challenge. I absolutely understand the rationale behind 42 CFR Part 2, but it is probably our biggest challenge in terms of true integrated care. Then just the cost of health information technology for our agencies—we don't have the same federal and state resources for technology that other health care providers have. Our agencies have been coordinating care with other providers, social service organizations, and primary care for decades, but it's seen as this new thing for the health delivery system at large and for technology platforms that are meant to support it.

Q: What are some of the advantages of working in your rural environment?

A: When you talk about integrated care, in some ways it is a lot easier in smaller communities where care providers know each other. The individuals and families they're working with are the same. Another big piece of rural health care delivery is that our agencies are so community oriented and mission driven. It’s not just about, "Oh, I'm providing a service to people I don't know.” They are our neighbors. They're our friends, community members who people will see in all different places. It's a different type of commitment to enable people to live healthy and safe lives in their communities. Services such as peer support services become stronger.

A lot of it is about relationships and not only initiatives. There are pros and cons, but the deep, deep commitment to caring for communities is so strong. It grounds people to the point of not being willing to give up on that, and not being willing to just say, "Okay, we can't make this work, so let's just focus on more meds." I think that strong commitment to your fellow community members makes it so that you really want to see them integrated into the community, being surrounded by family and friends, being true neighbors.

Finally, being rural means, you have to be creative and innovative to meet the needs of the community. Resources are scarce and our network agencies develop programming that is highly effective and tailored to their communities. In fact, our agencies are great collaborators with other community providers for this very reason – there aren’t many of you so you need to be creative and develop solutions that will work.

Q: What types of initiatives are you currently working on?

A: We’re working on a program called Vermont Care Partners Centers of Excellence, which focuses on improving the quality of services at each agency. It's a certification process we've developed to demonstrate our value to address the whole health of the populations that we're serving. As we move towards value-based payment mechanisms, we need to demonstrate outcomes in a standardized way across the system. We're really trying to focus on how do we do that together as a system. We found that there isn't a great certification process out there that really focuses on community-based mental health, substance use, and developmental disability services. The National Council for Behavioral Health had worked with Dale Jarvis, who had created five pillars of the Centers of Excellence. Through a Centers of Excellence committee with representatives of every agency, we worked through what we meant by those five pillars and how we could measure that. We developed a certification manual and piloted it with three agencies, and we’re now rolling it out to the entire network. It’s proven to be extremely beneficial to the agencies, is being recognized nationally and is informing our payment reform processes.

Within Vermont Care Network, we try to focus on standardization as much as possible – whether it is about our EMRs, our coding, how we screen for social determinants, or how we survey our clients. All of this impacts our data. It impacts our analytics. It impacts our cost of services. It impacts how we are perceived as a network. So, we push for standardization, but we always, always say, "We need to do as much of this together while still allowing for you to meet your individual, community, and regional needs."

Q: Based on your experience as a network leader, what advice would you give to a developing rural health network?

A: We don't all need to reinvent the wheel. I've spoken to a few people about the development of our data repository and the lessons learned. Peer learning and sharing has always been really helpful to me. Don't try to do everything yourself. There are a lot of people out there who have been doing this for a long time, and they can share what works and what doesn't. I think sometimes what doesn't work is just as important as what does. Almost every day as we are working on one initiative or another, I think "there's got to be some template out there."

Then I would say really building relationships with your stakeholders, with your state government, with consumer groups, with other advocacy trade associations, primary care, all the different people out there doing similar things and maybe with a slightly different lens. We all live together in this rural state so having positive productive relationships is imperative. We’re integrating our work and trying to do as much together with our primary care association, the State, the ACO, community based providers and more in order to find that common ground and develop some infrastructure to support the network to provide the highest quality care in regions throughout the state. We have it pretty easy in Vermont because it is a small state built on relationships. People are accessible, easy to work with and committed to Vermonters.

We’ve established good relationships, and we’re really appreciative for that. We always do National Council Hill Day, which I think is important. A lot of our network members go up with us and meet with them as well. We're ensuring that we focus at the federal level, the state level, and then the local level work.