INFORMATION FOR
HEALTH INSURANCE PLANS
The VillageHealth Approach to Disease Management
Disease management encompasses integrated care across all settings. Every component of patient care is tracked by a dedicated information system. The key to the program's success is the VillageHealth Nurse (VHN), a locally based nurse with many years of ESRD experience. This individual coordinates care across all disciplines and expedites necessary referrals. With rapid attention to patient needs, there is a significant reduction in hospital admissions, hospital length of stay, and emergency room visits. Patient health status stabilizes and may improve as we become more familiar with the patient's total physical and psychosocial needs.
Program Objectives
Key elements of the VillageHealth Disease Management program are:
- Evidence-based guidelines/management plan
- Identification and management of risk factors and comorbidities
- Data management tools
- Coordination of care with PCPs, case managers, nurses, nephrologists, and other specialists
- Quality-of-Life improvements
- Process measurement and quality improvement
- Patient health education and self-management
The VillageHealth Disease Management program is based on our extensive experience and understanding of the needs of renal disease patients. Early education and identification of patients with renal disease can lead to:
- Initiation of therapy to slow the progression of kidney failure and therefore 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 comorbid conditions such as diabetes, cardiovascular disease, congestive heart failure, and peripheral vascular disease, with decreases in ER 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
VillageHealth DM Delivery Model
- Combined field and telephone model
- Multidisciplinary renal care team - RN's, Regional Medical Director
- Predictive modeling and HRA to rank and stratify members
- Patient stratification drives interventions
- VH Medical Director oversight through frequent interaction with VH team
- Hospital admissions/discharges tracked and managed to slow "revolving door"
- Monitoring devices for "high-risk" members
- Provider outreach and communication
- KEYConnections Education program delivered via mail, telephone, in person, or Web
Care Management Strategy
VillageHealth Is a Leader in Disease Management
The United States Renal Data System (USRDS) annually sets benchmarks for multiple areas of clinical outcomes. The outcomes of VillageHealth Medical Management delivered over the years have exceeded the USRDS benchmarks for performance.
VillageHealth is the first renal disease management organization to achieve full accreditation from the National Committee for Quality Assurance (NCQA), and is the largest renal disease management company in the United States. We have advanced care management programs in 22 states and are currently managing over 6,000 patients.
