INFORMATION FOR
HEALTHCARE PROFESSIONALS
CKD and ESRD Advanced Care Programs Offer Flexibility
Advanced Care Management
The VillageHealth Advanced Care Management programs offer a focused approach to patient care. Patient management is led by the primary care physician and nephrologist, coordinated by the VHN, and applied by the care delivery team.
Coordination of care helps to achieve the most cost-effective use of resources. This is accomplished by assisting patients in obtaining the most appropriate healthcare as well as social and support services. The Advanced Care Management program utilizes a range of management approaches from telephone contact with patients to extensive and regular face-to-face contact, depending on patient needs.
The VillageHealth program also monitors the progression of renal disease, initiates early referral to nephrologists, recommends appropriate placement in an outpatient setting, and provides psychosocial support as the progression of the disease occurs. The program also focuses on the prevention and management of associated comorbidities.
The Advanced Care Management program utilizes a comprehensive 4-step process:
- Patient Assessment: The VHNs begin with a comprehensive personal assessment of the patient's current needs. In addition, at least six months of medical records are reviewed. The patient then is risk adjusted into high, medium, and low risk.
- Care Plan Development and Collaboration: The VHN meets with the primary care physician/nephrologist to review the data and develop a care plan. Lab requests pursuant to the suggested guidelines of care are given to the patient.
- Care Plan Implementation: Once the care plan is outlined, it is communicated to relevant providers. The VHN then provides advanced care coordination complemented by an intensive educational program to address identified issues and co-morbid conditions. A Service Intensity Guide provides services guidance for the VHN relative to the risk severity.
- Continuous Quality Improvement meetings: VillageHealth establishes a quality care committee, which meets regularly to review clinical outcomes and discuss operational issues. Outcomes data discussed at the meetings form the basis for the development of future continuous quality improvement activities.
ESRD Program Description
The VillageHealth ESRD Advanced Care Management program is based on our extensive experience and understanding of the specialized needs of ESRD patients on dialysis, the drivers of ESRD resource utilization, and the modifiable clinical conditions that are present in this vulnerable population.
Key benefits of the VillageHealth ESRD Disease Management program include:
- Evidence-based clinical guidelines/management plan
- Identification and management of risk factors and comorbidities
- Data management tools
- Coordination of care among PCPs, case managers, nurses, nephrologists, and other specialists
- Quality-of-life improvements for patient
- Process and outcome measures benchmarked for quality improvement activities
- Patient health education to promote self-management of their conditions
CKD Program Description
The VillageHealth CKD Advanced Care Management program is based on our extensive experience and understanding of the needs of CKD patients, the drivers of CKD resource utilization, and the modifiable clinical conditions that are present in this vulnerable population.
Services provided by the VillageHealth CKD Advanced Care Management program include:
- Initiation of therapy to slow the progression of kidney failure and decrease the prevalence of ESRD
- Effective treatment of complications of CKD (e.g. anemia, bone disease, and malnutrition) with improved survival and quality of life
- Appropriate identification and management of co-morbid conditions such as diabetes, cardiovascular disease, congestive heart failure, and peripheral vascular disease, with decreases in emergency room visits and hospitalizations
- A smooth transition to renal replacement therapy (dialysis or transplantation), when needed, avoiding emergency hospitalization for initiation of dialysis with the high associated clinical morbidity and costs
