Comprehensive Care When and Where It’s Needed
VNSNY Care360° Solutions is uniquely positioned to coordinate and deliver care for your members most at risk for hospital readmissions, helping to improve their health, enhance their care experience, and reduce health care costs.
Transitional Care Management
Designed to prevent readmissions for your high-risk members following discharge from an acute care facility by supporting a safe transition home and managing post-acute recovery across a 60 to 90 day period.
Transitional Care with Home Care
Tailored specifically for your high-risk members who require in-home skilled nursing and/or rehabilitation care, our care management services prevent readmissions following hospital discharge by facilitating a safe transition home and supporting post-acute recovery across a 60 to 90 day period.
Longitudinal Care Management
Customized for your high-risk members with complex needs, including multiple chronic illnesses and lack of social supports, who would benefit from longer-term care management support across a 12+ month period.
Advanced Illness Management
Advanced illness management and support for advance care planning are essential elements of all VNSNY Care360° Solutions. A proprietary algorithm is used to identify and engage members who could benefit from advance care planning conversations, and a specially trained team is available to facilitate linkages to hospice care when appropriate.
Our Model of Care
Rooted in population health best practices, the VNSNY Care360° Solutions model applies
evidence-based, integrated clinical care activities designed to effectively manage
medical, social, and behavioral health conditions. Key features include:
Interdisciplinary team of experts, anchored by nurse care managers with significant experience in evidence-based interventions and managing chronic conditions, including heart failure, COPD, and diabetes.
Best-in-class risk stratification and analytics, which enable us to customize care and meet needs of individual members and at-risk populations.
Clinical expertise and breadth of services to address a spectrum of medical, behavioral, and social needs.