VillageHealth is changing the way renal care management services are delivered. We use an Integrated Care Management (ICM) approach to make sure valuable resources are efficiently and effectively used to create an optimal patient experience producing better clinical outcomes.
VillageHealth’s ICM approach emphasizes kidney-specific interventions, co-morbid management, coordinated care and patient activation for each member. The benefits include fewer hospitalizations, coordinated care across all providers, activated patients with increased levels of engagement in their own care, and an ‘extra set of hands’ to help the member follow their treatment plan.
The components of Integrated Care Management combine best practice kidney care management protocols with a highly integrated care delivery system and new, innovative technologies that enhance patients’ access to care and providers’ ability to seamlessly collaborate.
During the first 15 days in which a patient is in the VillageHealth program, the VillageHealth Nurse (VHN) conducts an initial patient assessment. The assessment contains baseline information including:
- basic needs such as housing, food, transportation, caregivers
- patient activation measures
- vascular access type
- gastrointestinal assessment
- medications and allergies
- comorbid conditions
- depression screening
- transplant referral evaluation
After the initial assessment a patient is assigned a service intensity level of high, medium or low. This score determines the intensity of nurse coaching needed to achieve better clinical outcomes. For example, the score changes with the patient’s health status: a patient with a “low” service intensity rating would move to “high” following a hospitalization or sentinel event, for example.
This model enables the VillageHealth to customize engagement with the member by increasing or decreasing the intensity of coaching based on the member's specific needs.
Click here to contact VillageHealth for more information.
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