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VNSNY Population Health Initiative

healthcare planning
A population health initiative among health plan members with chronic conditions demonstrated:

  • Greater engagement–in fact exceeded target engagement rate
  • Reduced utilization
  • Lower costs

The Need

A leading employer-based health plan identified a large population of “well working” members with chronic conditions

  • Vulnerable, frequently unstable population, likely to have diabetes
  • Often medically complex with multiple social determinants of disease
  • Putting significant strain on health plan costs

Program Overview

The health plan came to VNSNY. Together, we co-created a Population Health Management program to identify and manage plan members who have or were at risk of developing common and costly chronic conditions, such as:

  • Diabetes
  • Hypertension
  • Osteoarthritis
  • Asthma
  • Hypercholesterolemia
  • Cancer
  • Depression

Program design addressed needs of participants with a suite of proactive health and wellness services.

Program Objectives

  • Improve quality of care, including better adherence and reduction of risk behaviors that impede health
  • Improve member satisfaction through empowerment to engage and take control of self-care
  • Reduce cost of care

Key Program Elements

Risk assessment and stratification

  • Member health data analyzed, focusing on ‘at-risk’ patients
  • Participants stratified according to health plan’s predetermined metrics and then via VNSNY predictors of risk

Personalized action plan

  • Health Buddy (certified VNSNY Population Care Coordinator or Registered Nurse) invites participant to enroll
  • Builds care profile of member’s health and well-being
  • Helps member set goals and develop plan to meet them

Care management

  • Activities led by Health Buddy, part of the Population Health Team
  • Population Health Manager (PHM) schedules regular follow-up sessions with Health Buddy to help member achieve goals
  • Follows member until graduation or when goals have been met (approximately three months)

Coaching and support

  • Telephonic and on-site outreach by plan nurses
  • Educational tools provided to members


Engagement rate (primary metric) 1

  • Exceeded target goal, with 25% of plan members enrolled vs. target of 20%

Quality of life 2

  • QOL score 4-5 at completion of program (Likert 5-point scale)

Positive financial impact 3

  • Reduced utilization

1Based on Adjusted Engagement Rates from Health Plan Dashboard. July 2015. Rates adjusted to reflect those unable to contact, wrong phone number, ineligible, and closed.
2Average Quality of Life Scores, based on VNSNY Quality Audit. January 2014-July 2015.
3Based on health plan’s analysis. February 2015.

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