Waivers as Catalysts for Rural Health Innovation

Healthcare innovation is powered by flexibility and collaboration. As an accountable care organization (ACO) responsible for healthcare cost and quality outcomes, OneCare Vermont benefits from special permissions—known as “waivers”—granted by the Centers for Medicare & Medicaid Services (CMS) and the Department of Vermont Health Access. These waivers ease certain federal requirements, such as those governing referrals and payments, when arrangements advance value-based care goals.

Far beyond regulatory relief, waivers serve as strategic enablers of innovation. They allow providers to work together more effectively, reduce duplication, and deliver coordinated, patient-centered care. OneCare Vermont pairs these waivers with targeted funding to launch pilots that address critical needs across the state–helping to avoid unnecessary emergency department visits and hospital readmissions, expand access to care including mental health services, facilitate timely hospital discharges, and improve health outcomes for chronic conditions such as high blood pressure and diabetes.

This article highlights some of the value-based innovations OneCare facilitated by using regulatory flexibility and funding to enhance Vermont’s care delivery model.

Reducing Emergency Department Utilization and Hospital Readmissions

Chronic wounds, such as diabetic foot ulcers, pressure ulcers, and venous stasis ulcers, are increasingly recognized as leading causes of frequent hospitalization, prolonged hospital stays, and emergency room visits. To improve the approach to wound care treatment, the Coordinated Wound Care Nurse Program Collaborative was developed in partnership with Addison County Home Health and Hospice, Porter Medical Center, and Helen Porter Rehabilitation and Nursing. This initiative, made possible by waivers, enables specialized care to patients who often bounce back and forth between acute care locations and long-term home settings in a pattern that is largely avoidable.

The funding from OneCare for this initiative supported care coordination and non-reimbursable services, including the deployment of a wound-certified clinician to the patient, rather than the patient’s setting. This specialist provides continuity of care across settings, improving outcomes, and reducing costly complications such as emergency department visits and hospital readmissions. The role of the wound care nurse is critical in overseeing wound healing, coordinating care between multidisciplinary teams, and ensuring that patients receive timely interventions to prevent unnecessary transitions to higher levels of care. In addition to this direct patient care role, the wound care nurse provides education to nursing homes and hospital staff.

The program has demonstrated significant impact in reducing hospital readmissions, enhancing wound healing rates, and improving the overall quality of care for patients. In 2024, the wound care nurse made hospital visits and provided guidance on wounds for 44 unique patients. Of those, seven patients were readmitted for additional wound care, resulting in a 16% readmission rate. Data from January 2025 through August 2025 showed that 38 unique patients were provided wound care guidance, and none of those patients returned to the hospital from the long-term care facility for wound care, demonstrating a significant improvement in readmission rate and an estimated cost savings of $325,500 over the course of the program from the previous year. And importantly, patients were able to stay in their home environment with family and friends while receiving continuity of care.

Another innovative program facilitated using waivers and funding is the Mobile Integrated Health (MIH) program launched by Brattleboro Memorial Hospital (BMH) in partnership with Rescue, Inc., a local EMS program. Supported by a OneCare waiver and special funding in 2024 and 2025, the program delivers in-home care to patients with Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF) – two populations at high risk for emergency department (ED) visits and hospital readmissions. Through personalized action plans and in-home care, the program ensures safe transitions from hospital to home, reduces unnecessary visits, and improves health outcomes.

When Gus was discharged from the hospital, he was met by an EMT from Rescue Inc. on the same day as part of the MIH program. The EMT spent time with Gus and explained the MIH Program in detail. “It’s an amazing program,” said Gus. “They are very well trained, polite, courteous, and non-judgmental. They set up a program for me where they come to my house automatically every three months. But if I have a problem between visits, I have a special number to call, and they will come to see me that day. I called once when I was feeling sick, and they came within two hours. They spoke directly with my PCP and were able to confirm the medications I needed to start taking.” This proactive approach prevented confusion and stabilized Gus’ condition, avoiding an unnecessary trip back to the emergency department.

The MIH program has produced measurable reductions in hospital readmissions and ED visits, yielding significant cost savings. As of 11/30/2025, 74 patients with either COPD or CHF have benefited from this program.

Expanding Access to Care, Including Mental Health Services

In rural Vermont, it is well known that access to psychiatric care is lacking, particularly for children. For mental health crises, families often utilize the emergency department to meet their needs. With the assistance of OneCare’s waiver flexibilities and funding, a Chittenden County pediatric practice has been able to integrate a consulting psychiatrist into their practice for up to 25 hours per month for psychiatric care consultation. This additional resource allows for greater collaboration amongst providers, reduces costs of emergency department visits, and provides faster access to psychiatric services for children. As a result of this program, wait times for mental health services have been reduced from six months to one month or less. Additionally, pediatricians can receive consultation to provide more proactive support for children presenting with complex psychiatric needs.

Responding to increased wait times and access issues in Vermont emergency departments (EDs) due, in part, to the significant increase in patients experiencing mental health crises visiting local EDs, hospitals and policy makers were looking for creative solutions. “As the pandemic began to ease, we often had open beds, and patients in EDs who needed them, but had no way to get here,” says Elizabeth Wohl, Chief Legal Officer at the Brattleboro Retreat. The Brattleboro Retreat, whose mission is to provide comprehensive mental health services, stepped up to provide an innovative solution by leveraging OneCare’s waiver flexibility. The Brattleboro Retreat joined forces with Rescue, Inc, where a capacity fee is provided to make available a dedicated ambulance and a specially trained crew to transport patients seeking inpatient psychiatric care from emergency departments to the Retreat. Access to this transportation shortened ED wait-times and improved access to care at the correct setting. This waiver facilitated personalized treatment in a supportive environment where healing begins and hope is restored, supporting patients in their journey to recovery. In 2024, a total of 321 completed transports to the Brattleboro Retreat were made.

Facilitating Hospital Discharge

One of the primary barriers to safe and timely discharge of patients from the acute hospital setting is the inability to obtain adaptive equipment and mobility assistance devices for patients that are otherwise medically ready to leave the hospital. There are many reasons for these delays which could include lack of insurance coverage as well as procurement issues. OneCare was able to provide waiver support and funding to the University of Vermont Medical Center Acute Rehabilitation Therapies Department in the amount of $36,500 to help provide the purchase of adaptive equipment and mobility devices that facilitate safe and functional independence to patients in their home. As of 9/5/2025, 38 patients have received equipment, amounting to $16,180 in expenditures, to facilitate their discharge and to ensure their safety. Examples include grabbers, shower chairs, dressing sticks, commodes, and tub transfer benches. Assuming a hospital day, estimated to cost approximately $3,000, was saved by facilitating timely discharge for these patients, the program provides an enormous opportunity in healthcare cost savings.

Another highly successful waiver granted by the Centers for Medicare and Medicaid Services (CMS) available for OneCare’s use is the 3-Day Skilled Nursing Facility (SNF) Rule waiver. This waiver allows providers to bypass the traditional Medicare requirement that a patient must have a three-day hospital stay before being admitted to a SNF for a subacute or rehabilitation stay. This flexibility means patients can transition more quickly to the appropriate level of care—improving outcomes and freeing up hospital capacity for those who truly need it. In 2024, 299 patients benefited from the waiver. Of these, 126 patients were admitted directly from the emergency department to a SNF, bypassing the need for a three-day hospital stay. This direct transfer model not only improved patient experience but also generated significant cost savings—approximately $3,000 per patient per day and has saved conservatively at least $2 million in hospital expenses in 2024. Between January and September 2025, 228 beneficiaries utilized the waiver, with 80—approximately 35%, originating from observation status. Most diagnoses were linked to non-surgical orthopedic admissions, including fractures, musculoskeletal conditions, falls, and rehabilitation needs.

“SNFs provide personalized and attentive care, allowing patients to recover in a potentially more comfortable and less intensive environment than the hospital setting,” remarks Dr. Carrie Weigand, OneCare’s Chief Medical Officer. “Early and seamless transfer to a skilled nursing facility allows for timely rehabilitation and recovery, continuous and coordinated treatment, and potentially reduces complications while improving overall health outcomes and patient experience.”

Improving Health Outcomes for Chronic Conditions

At the University of Vermont Health Care Management program, one area of focus is on controlling high blood pressure. Through an inter-disciplinary team that includes RN care managers, health and wellness coaches, primary care providers and pharmacists, patient lists are reviewed for outreach, and a patient-centered plan is created for those with diagnosed and documented uncontrolled hypertension.

To support their work, OneCare provided waiver support and funding to purchase validated blood pressure cuffs to those who could benefit clinically from using the equipment. One primary care practice indicated, “We have even had a couple of patients whose hypertensive medication regimen was adjusted without having to come in for visits to the office. They provide us with 12-14 readings over two weeks, and we average them to see if they are above/at/below their blood pressure goal. This process has enabled providers to safely change blood pressure medications with home blood pressure readings and order follow-up labs. Being able to give patients’ blood pressure cuffs to take home with them seems to help motivate patients and provide more education surrounding their blood pressure. It is fun to see patients reach their goals.” One RN care manager continues to work with a patient with hypertension who was provided with equipment and trained to use it. She has successfully taken her medications to control high blood pressure, provided readings to her primary care provider and was recently told that she could go down to checking her blood pressure and reporting it to a schedule of once/month. The patient reports that she feels she is “graduating” and is feeling less apprehensive about potential complications from uncontrolled high blood pressure.

Separately, Thomas Chittenden Health Center focused on improving diabetes control by facilitating access to continuous glucose monitors (CGM) for those who do not meet qualifications for insurance coverage (most require patients to be on once daily insulin injections). Access to the CGMs was made possible through OneCare’s waiver and incentive funding and has been critical to the success of this program. The targeted population of patients with type 2 diabetes, on one or no medication, worked closely with a registered dietitian/certified diabetes care and education specialist over 12 weeks in three one-on-one appointments. They were able to clearly see the effects of dietary and activity choices on their glucose control, make desired changes, set a personal SMART goal and see the outcome in a post HbA1c reading (HbA1c is a measure of glucose control with a lower number representing better control). Thomas Chittenden saw improvements in overall diabetes control in their population and as of August 31, 2025, those completing the three-month program had an average reduction of HbA1c from 7.1% to 6.4%. A secondary finding was weight loss for most patients. All patients expressed how useful a tool, like CGM, was in helping make informed decisions about their diabetes.

One patient remarked, “I love having this information because it is not what I expected. I would wear one of these forever if I could.”

With the support of OneCare’s waiver and incentive funding, The University of Vermont Medical Center was able to provide Medical Nutrition Therapy (MNT) for a broader range of medical conditions beyond traditional diabetes and chronic kidney disease, the only approved indications covered by CMS. The waiver has extended nutrition therapy to individuals managing chronic conditions such as cardiovascular disease, hypertension, gastrointestinal disorders, cancer treatment and recovery, obesity, metabolic syndrome amongst other nutrition-related health concerns. This allowed delivery of more comprehensive, evidence-based care and ensured more patients could benefit from therapeutic nutrition services when needed. Nutrition plays a critical role in nearly every chronic condition, yet many patients do not receive support until their illness is well advanced. Use of OneCare’s waiver allowed clinicians to refer patients for MNT at the earliest sign of risk. Registered dietitians provided individualized education that helped patients understand their condition, make informed food choices, develop realistic and culturally appropriate eating plans, and build confidence in managing their health. This patient-centered approach supported sustainable behavior change and long-lasting improvements in well-being. Since the waiver’s implementation in 2023, outpatient dietitians have provided care to 1,330 Medicare patients who may not have otherwise been able to access MNT to help improve their health.

Through these initiatives, OneCare demonstrates how waiver-driven flexibility can spark innovative solutions that improve quality, lower costs, and strengthen health equity for rural and underserved communities. By responsibly and transparently leveraging fraud and abuse waivers and benefit enhancement waivers, OneCare demonstrates how care enhancements can be accelerated within an accountable care framework while maintaining compliance and accountability.