VNSNY Care Management Solutions

No other community health care organization is better positioned to integrate and coordinate care for your members than VNSNY, helping you to improve the health of populations, enhance member experience and reduce health care costs.

Trusted by New Yorkers for over 125 years, VNSNY is deeply entrenched in the local community and intimately familiar with the unique challenges of managing care for diverse and complex populations. The individual has always been at the center of our care model and the community has always been our health care hub. This enables us to take a unique, locally integrated approach to care, that only VNSNY can provide.

Our model features:

Extensive interdisciplinary care management teams, anchored by Duke University-trained RN Population Care Coordinators, are trained in evidence-based interventions, and have significant experience managing chronic conditions and comorbidities, including heart failure, COPD, and diabetes. We see your members in all settings and through acute episodes and long-term chronic diseases.

Best-in-class risk stratification and analytics enable us to customize and effectively manage care using a dosed mix of in-person, telephonic, and remote monitoring to meet the needs of individual members and at-risk populations.

Clinical expertise and breadth of services to address a spectrum of medical, behavioral, and social needs.

As a leader in Care Management, VNSNY has experience working with a range of customers — from payers to hospitals to ACOs and CBOs — developing tailored solutions for a variety of population needs across the care continuum. Our commitment to clinical quality, innovation, and person-centered care has enabled us to achieve excellent outcomes.

VNSNY’s core Care Management programs include:

Post-Acute Care Management
Complex Chronic Care Management
Demonstrated Outcomes

Post-Acute Care Management

VNSNY’s Post-Acute Care Management solution focuses on members recently discharged from an acute facility who are most at risk for re-hospitalizations and extended skilled nursing facility stays. Using evidence-based, interdisciplinary clinical and behavioral activation activities tailored for each member, we can effectively manage the medical, social, and behavioral conditions that influence post-acute recovery. Over a defined time frame, our highly skilled care management team works collaboratively with your existing network partners to ensure the most appropriate care is provided in the most appropriate setting at the right time.

Key program elements may include:

Initial in-person visit for comprehensive assessment and risk stratification
Facilitation of out-patient visit within 7–10 days
Coordination of care with post-acute care providers, such as home care, skilled nursing facilities, and CBOs

Complex Chronic Care Management

VNSNY’s Complex Chronic Care Management solution is designed to manage high-risk, complex members — those often struggling with multiple chronic illnesses, lack of social support, and self-management challenges. We use an integrated care coordination approach to effectively manage the clinical and psychosocial needs over an extended time frame. Working in collaboration with your existing network partners, our care management experts will screen for risk factors, and develop a customized plan of care.

Key program elements may include:

Member and caregiver education, including self-management techniques and addressing identified barriers to self-management
Coordination before and after physician appointments; ongoing communication with PCP and specialists as needed
Remote patient monitoring and virtual visits to proactively track members’ progress
Activation of health coach to perform environmental and home assessments for identification of triggers and social determinants of health and navigation with assets in the community
Deployment of an NP to the home to address urgent and emergent conditions, to perform medication titration, or to provide medical consults as requested by the PCP

Demonstrated Results of VNSNY Care Management

VNSNY Care Management programs have shown outstanding results:

Leadership in CMS cardiac bundled payment initiative reduced readmissions and achieved over 8% reduction in total cost of care

VNSNY served as full risk-bearing, single awardee participant in CMS Bundled Payments for Care Improvement (BPCI) Model 3 initiative, and was one of initial model participants in NY area
Successfully managed Medicare heart failure patients to improve quality, reduce total 90 day episode costs and enhance patient experience
Achieved over 8% reduction in total cost of care and reduced in-patient events compared to baseline

Reduced hospitalizations and surpassed PCP appointment adherence goals among high-risk health plan members

VNSNY Care Management reduced hospitalization rates against baseline among high-risk health plan members receiving VNSNY home care services
Surpassed PCP appointment adherence goals

Successfully managed ED utilization and rehospitalization rates for complex Health Home population

Utilized comprehensive care coordination to address medical and behavioral service needs
Exceeded goal for ED utilization rates by 13 percentage points (12% vs 25% target)
Surpassed target in-patient hospitalization rates by 11 percentage points (4% vs 15% target)

*based on patient reported data

Improved HEDIS measures and reduced rehospitalization risk for psycho-socially complex populations

As part of VNSNY’s Behavioral Health Community Transitions program, used LCSW transitional assessment and collaborative approach to bridge gaps during transition from hospital to community, promoting patient health and stability
Demonstrated improvements across HEDIS measures, surpassing New York state benchmarks for face-to-face follow-up visits completed within 7 and 30 days post-discharge