Persons with complex health conditions and psycho-social needs may benefit from a wide variety of medical and social services from many different providers. It is essential that the care provided to these persons is not “fragmented,” with different agencies providing care in multiple locations without communicating adequately with each other. Fragmentation of care can cause confusion and challenges following care plans; over-treatment and uncontrolled costs through unnecessary tests or duplication of services; or under-treatment and poor outcomes based on incomplete information or misidentification of the person’s primary health determinants. An Integrated Care Management (ICM) model has been shown to improve health outcomes and decrease healthcare utilization by refocusing care on social determinants of health, supporting shared care planning across multiple organizations, and encouraging involvement of participants in planning their own care. Between January 2015 and December 2016, Vermont implemented an Integrated Care Management (ICM) model with the goal of making health care more person-directed, progressive, and non-episodic. Funds were provided through a State Innovation Models Testing grant from the federal Center for Medicare and Medicaid Innovation, with support from the Vermont Program for Quality in Health Care, the Green Mountain Care Board, and the Vermont Blueprint for Health. Over 200 professionals from more than 100 agencies in 11 communities attended statewide trainings on community-based care-planning, root-cause analysis, shared-care plans, eco-mapping, and disability awareness. Providers reported increased clarity and accountability within interagency teams, improved linkages between goals and interventions, and empowered/active patient participants. As of December 2016, over 300 persons with complex needs have participated in ICM. Approximately 90% reported feeling supported by their care team and being actively involved in defining future goals. Communities are also starting to see reductions in Emergency Department use among ICM participants, with one community reporting a 51% average decrease for 12 patients. Further evaluation of clinical outcomes and cost savings using Vermont’s all-payer claims database is planned for 2017. Provider and participant feedback on the ICM model in Vermont has been overwhelmingly positive. Along with continued State engagement, many communities have developed and presented local training sessions, supporting long-term sustainability of the work.