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Population Health Management at VNSNY

As a leader in Population Health Management, VNSNY has experience in working with a range of customers—from hospitals to ACOs to payers—and on a variety of initiatives, including value-based purchasing, bundled payments, and chronic care management.

Our unique approach is built around a proprietary VNSNY Risk Stratification Model and predictive modeling capabilities. We have invested in building our team’s skills and capabilities, and registered nurses on our teams have received advanced training as Population Health Coordinators through the Duke University School of Nursing. Our commitment to clinical quality, innovation, and patient-centered care supporting the Triple Aim has enabled us to achieve excellent outcomes.

VNSNY’s Population Health Management programs address patient needs across the care continuum:

Gaps in Care Management

This program targets healthy patients or those with chronic conditions who need easy access to preventive services. Information is collected from payers and providers to inform a patient registry and risk stratification. Automated prompts and alerts are programmed into the registry and customized according to targeted metrics. A Health Coach or Population Care Coordinator provides specific telephonic interventions, including patient education, appointment reminders, and connection to community resources.

Chronic Disease Management

This program targets patients with chronic conditions, along with other underlying risk factors, who could benefit from education promoting plan of care adherence and independent disease self-management. Key program elements include:

  • Patient and caregiver education, including disease self-management, medication management, and appointment adherence
  • Coordination before and after physician appointments, ongoing communication with PCP and specialists as needed
  • For rising- and high-risk patients, face-to-face visits with patient and caregiver as needed

Transitional Care Coordination Program

This program is targeted at patients hospitalized within the past seven days who have clinical and psychosocial barriers to obtaining needed care. Key program elements include:

  • In-person visit in hospital or home for comprehensive assessment and risk stratification
  • Communication with PCP on hospitalization course and transmission of hospital discharge summary
  • Facilitation of physician visit within 7–10 days, and ongoing disease management interventions
  • Coordination of care with post-acute care providers (home care, skilled nursing facilities)

Certified Home Care Episode

The target population for care is homebound patients requiring skilled, home-based nursing and/or rehabilitation services as part of a physician-ordered plan of care. Key elements include:

  • A range of skilled nursing, behavioral, or rehabilitation therapy services
  • Education of patient and family in self-care, disease treatment, and prevention
  • Coordination of care across multiple disciplines and transitions of care
  • Specialized care for patients with a high risk of hospitalization

Excellent Outcomes Have Been Demonstrated

VNSNY Population Health Management programs have shown outstanding results with leading managed care payers:

  • Among high-risk health plan members, our Transitional Care Coordination program exceeded its goal for reducing 30-day readmissions1 and achieved 100% adherence to follow-up appointments2
  • Among medically complex health plan members, our Chronic Disease Management program exceeded its target engagement rate3 and reduced utilization4

1 VNSNY Weekly Program Status Report. January 29, 2015.
2 VNSNY Weekly Program Status Report. November 17, 2014.
3 Based on Adjusted Engagement Rates from Health Plan Dashboard. July 2015. Rates adjusted to reflect those unable to contact, wrong phone number, ineligible, and closed.
4 Based on health plan’s analysis. February 2015.

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