INFORMATION FOR
HEALTHCARE PROFESSIONALS
Services Provided by VillageHealth Disease Management
VillageHealth Disease Management offers programs for renal patients who have CKD but do not require renal replacement therapy, as well as patients who have developed ESRD and require dialysis.
Most CKD and ESRD patients have three to four comorbid conditions by the time their renal disease is detected, and these conditions are difficult to manage. Our program is unlike other disease management programs because we partner with all healthcare providers and we:
- Value the local provider community input, feedback, and support of the program
- Engage the provider community during the rollout process and through local quality committees to focus on Continuous Quality Improvement (CQI)
- Integrate with the existing payer network so patients continue to see their current providers
With trained nurses coordinating patient care, we can provide the specialized education and tracking that CKD and ESRD patients require. We emphasize the leadership role of the nephrologists with the use of clinical guidelines to manage the continuum of illness from CKD through ESRD. Our focus is on the total patient and the factors that put them at risk for further deterioration in their health. This leads to improved quality of life for patients, improved clinical outcomes, and lower overall costs.
The key services provided by this program include:
- A rigorous core team approach to ensure that patient, processes, and outcomes are continually evaluated and improved
- Evidence-based clinical guidelines/management plan
- Identification and clinical management of risk factors and comorbid conditions
- Provider community involved in CQI
- Coordination of care among PCPs, case managers, nurses, nephrologists, and other specialists
- Field-based renal specialty nurses supplemented by telephonic capability
- Quality-of-life improvements for patients
- Process and outcome measures that have been benchmarked for quality improvement activities
- Patient health education to promote self-management of their conditions
- Data management tools
- Set financial and clinical targets associated with a risk structure
- A variety of standard analyses and reports available to monitor the program
