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