Best-In-Class Care Rooted in Population Health
VNSNY Care360° Solutions uses evidence-based, integrated clinical care activities tailored
to effectively manage members’ medical, social, and behavioral health needs.
Our care management capabilities build on our significant experience and expertise in caring for vulnerable patients and members in their homes. As illustrated by our leadership in Population Health, we’ve seen continued results demonstrating our ability to improve quality, enhance experience of care, and reduce costs.
The launch of VNSNY Care360° Solutions provides high-risk patients and members with enhanced care management services in a home-based setting, keeping them out of the ED and the hospital.
Our unique approach is built around VNSNY Care360° Solutions’ proprietary risk stratification and predictive modeling capabilities, as well as our highly skilled care management team.
Population Health Leadership
As a leader and pioneer in population health management, we have experience implementing a variety of innovative strategies to manage special populations, including bundled payments, health homes, care transitions, hospital at home, and chronic care management.
Caring for medically and psychosocially complex patients is what VNSNY does best. Our average patient has multiple comorbidities—including heart failure, COPD, wound and ostomy needs, and behavioral health and social issues—and requires extensive care coordination across providers and across settings.
Interdisciplinary Team of Experts
Our team’s unique mix of staffing disciplines provides an extra level of support for members. In addition to assigned care managers consisting of registered nurses, therapists (PTs, OTs), and social workers (LCSWs and LMSWs), the team draws on the expertise of nurse practitioners (NPs), pharmacists, transitional care associates, registered dietitians, advanced illness management experts, and wellness coaches.
Licensed clinicians are deployed into members’ homes as needed, including NPs who:
- Treat a variety of urgent and emergent conditions to avert unnecessary ED visits and hospitalizations
- Provide primary care follow-up within 10 days after hospitalization if the member’s PCP is unavailable
Member education and support are an important part of the care model, with wellness coaches, transitional care associates, and social workers available to provide:
- Member and caregiver education, including self-management techniques
- Environmental and home assessments to identify triggers and social determinants of health
- Support navigating and connecting with resources in the community
Comprehensive Approach to Care
These core program elements create the foundation of our care management offerings.
Face-to-face assessment: Comprehensive, in-person evaluation by nurse at home or hospital bedside, including medication reconciliation
Proprietary risk stratification model: Proactively identifies members at highest risk for rehospitalizations
Interdisciplinary team: Unique mix of staffing disciplines provide coordination of medical, behavioral, and social services
PCP engagement: Ongoing communication with PCP and specialists as needed, including before and after physician appointments
Innovative technology: Leveraging best-in-class tools and resources, including remote patient monitoring and virtual visit technologies to proactively engage members
On-call NPs: In-home deployment of nurse practitioners for urgent or emergent conditions, to perform medication titration, or to provide medical consults
Advance care planning: Support for end-of-life care planning and identification of needs
Additional Benefits for Health Plans
In addition to the clinical and financial impact, the VNSNY Care360° Solutions model offers value specifically tailored to meet the needs of health plan customers:
- Seamless care integration: Integration with existing health plan care management team and collaboration with plan’s preferred network partners.
- Continuous data sharing: Timely sharing of HEDIS and supplemental data, monthly reports on member outreach and engagement efforts, and comprehensive case profile at conclusion of each member’s service episode to inform ongoing care.
- Innovative financial models: VNSNY offers a variety of risk-sharing reimbursement approaches and contract arrangements, and we have successfully partnered with health plans and providers to develop performance-based measures that reduce total cost of care while improving outcomes.