Your Best Partner in Community-Based Care

With a range of solutions that span the continuum of care, and a commitment to outcomes and innovation, the Visiting Nurse Service of New York is the one community partner you can count on for all your patients’ home health care needs.

• Unequaled Scale and Capabilities 
• At the Forefront of Innovation
• Disease-Based Clinical Pathways for Improved Outcomes
• Commitment to Evidence and Outcomes
• Leadership in Hospice and Palliative Care
• Seamless Integration of Patient Care
• Excellence in Population Health Management
• Exceptional Private Care Services

Unequaled Scale and Capabilities

VNSNY is the largest not-for-profit home health care organization in the US. From pediatrics to end-of-life, from acute episodes to complex chronic care, VNSNY offers an unsurpassed range of clinical solutions.

With a 24/7 care delivery model, contracts with every major insurer, and service areas spanning the NYC metro area, VNSNY has enormous flexibility in meeting your patients’ needs.

Our service areas are as follows:

• Certified Home Health Agency (CHHA): Covers the entire eight-county NYC metro region
• Hospice and Palliative Care: The only hospice provider serving all five boroughs of NYC
• Partners in Care private care affiliate: Covers the five boroughs plus Nassau, Suffolk, Westchester, and Rockland Counties

At the Forefront of Innovation

VNSNY offers unsurpassed experience in the rapidly evolving landscape of new models of care, cost containment, and quality initiatives:

• VNSNY is participating as the risk bearing, episode-initiating provider in a BPCI Model 3 initiative
• Participating in both Model 2 and Model 3 (multiple and single provider partners)
• One of the first Model participants in the NY area (heart failure initiative)
• Industry-leading experience utilizing evidence-based clinical pathways for joint replacement population

Additionally, VNSNY experience in DSRIP initiatives includes:

• Participating in all 14 DSRIP PPSs in our eight-county service area
• Active in multiple Health Information Exchanges

Disease-Based Clinical Pathways for Improved Outcomes

Leveraging evidence-based protocols grounded in our vast patient database, VNSNY develops care plans which optimize encounters and interventions, focusing on actions that are patient-specific and diagnosis- and acuity-driven.

VNSNY’s disease-based clinical pathways offer effective guidance for the treatment of patients with needs in areas such as cardiology, oncology, and neurology. These pathways help to standardize the process and quality of patient care delivery, and optimize quality outcomes.

Commitment to Evidence and Outcomes

At VNSNY, demonstrated outcomes are the results of an approach to care we call Bringing Medicine Home—partnering with providers to bring rigorous clinical discipline to the practice of healthcare at home. We are committed to co-creating evidence-based programs that improve quality and reduce avoidable hospitalizations and emergent care:

• VNSNY Cardiothoracic Post-Op program: patients surpassed seven out of seven CMS OBQI benchmarks for essential quality of life functions¹
• VNSNY Orthopedic Home Rehab patients had a rehospitalization rate of 2.8%²

In addition, the VNSNY Center for Home Care Policy & Research is the pre-eminent research center for home- and community-based care, and the only one of its kind in the US. The Center developed VNSNY’s proprietary algorithm for predicted risk of hospital readmission, a tool that has proved invaluable by enabling targeted interventions for individuals with identifiable clinical and psychosocial risk factors.

Leadership in Hospice and Palliative Care

VNSNY Hospice and Palliative Care is the only New York City hospice program serving all five boroughs. We provide customized care wherever the patient resides: whether it’s at home or in a nursing home, skilled nursing facility, hospital or inpatient facility.

Our primary objective is improving patient quality of life, with a focus on:

• Improved pain and symptom management
• Increased caregiver confidence
• Greater feeling of control for both patients and families

We offer 24/7 access to hospice experts for physicians, patients, and families to ensure our partners and patients have what they need. And, outstanding outcomes have been demonstrated:

• Average 30-day hospitalization rate of just 3.4%³
• 94% of caregivers would recommend⁴

In addition, to the core hospice offering, VNSNY has developed several unique hospice programs to meet the specialized needs of underserved populations:

• VNSNY Cardiac Hospice Program: to improve quality of life and reduce hospitalizations among advanced-state cardiac patients
• VNSNY Hospice for Veterans Program: one of just two NYC programs to be awarded Level Four We Honor Veterans status
• VNSNY Hospice Outreach: a pilot program designed to overcome the disparity in hospice utilization among African-American communities

Seamless Integration of Patient Care

VNSNY’s unmatched scope and range of clinical solutions enables our teams to deliver care across all settings—home, community, and facility. Furthermore, care can be integrated across VNSNY CHHA, hospice, and private care services to:

• Improve continuity of patient care
• Provide smoother transitions between settings
• Improve outcomes
• Increase patient satisfaction
• Improve medication reconciliation and management

In addition, upon admission to the CHHA, VNSNY patients are screened for gaps in advance care planning. This enables the VNSNY team to help facilitate education and assistance with advance directive considerations and planning, and early introduction of Hospice and Palliative Care options as appropriate.

Excellence in Population Health Management

VNSNY is committed to innovation, clinical quality, and outcomes in population health management. We offer analytics and predictive modeling capabilities, with programs addressing patient needs across the care continuum:

• Gaps in Care Management
• Chronic Disease Management
• Transitional Care Coordination
• Certified Home Health Care Episode

Excellent outcomes have been demonstrated with leading managed care payers:

• Among high-risk health plan members, a Transitional Care program exceeded target goal for reducing 30-day readmissions⁵ and achieved 100% adherence to follow-up appointments⁶
• Among medically complex health plan members, a Population Health program exceeded target engagement rate⁷ and reduced utilization⁸

VNSNY RNs have advanced training for certification as Population Health Coordinators through the Duke University School of Nursing.

Exceptional Private Care Services

VNSNY’s private pay affiliate, Partners in Care, is the New York City area’s largest licensed home care services agency, with over 11,000 home health aides. Care can be provided in the home, or in hospital, inpatient rehab, or nursing facilities.

To supplement or extend care beyond Medicare or other insured coverage, Partners in Care offers a full range of professional services, including:

• Private care nursing
• Assessments for home safety, falls prevention, PRI/Screen
• Care management
• Personal care and companionship

Our team of professionals are among the best-trained in the industry. Aides receive 50% more training than is required by New York State. And, we provide specialized training in disease-based care, including behavioral health management.

Excellent outcomes include:⁹

• Unplanned hospitalization rate under 2% (vs. 2013 national Medicare rate of 18%)
• Unplanned ED visit rate under 1%
• 86% of clients were likely to recommend
• 96% of patients keep the same aide to support continuity of care

<sup>1. VNSNY Key Clinical Indicators Report. March 1, 2013–March 31, 2014.
2. VNSNY Key Clinical Indicators Report, Intensive Rehab Program (ARB), January 1, 2014–December 31, 2014.
3. 2015 VNSNY HPC Enterprise Quality Dashboard (based on quarterly data submitted to CMS).
4. CAHPS 1st Quarter 2015 Caregiver Experience Survey. Data aggregates percent of caregivers who would “definitely” or “probably” recommend VNSNY Hospice.
5. VNSNY Weekly Program Status Report. January 29, 2015.
6. VNSNY Weekly Program Status Report. November 17, 2014.
7. Based on Adjusted Engagement Rates from Health Plan Dashboard. July 2015.
8. Based on health plan’s analysis. February 2015.
9. 2015 Partners in Care Private Pay Quality Scorecard.</sup>