Case Example
A Hidden Hip Fracture
Situation
- VNSNY Care360° Solutions Care Manager gets a worrisome call from visiting nurse; member’s home health aide informed nurse that the member had fallen, which member denied
Customized Interventions
- Care Manager deploys nurse practitioner (NP) to member’s home to perform an assessment and determine next steps.
- After noting that member’s right hip was deformed and that she couldn’t bear weight on the leg, NP conferred with Care Manager, who arranged for an immediate home visit from member’s primary care physician (PCP)
- Concerned about the possibility of a dangerous blood clot, NP stayed with the member until the doctor arrived
- PCP confirmed hip fracture and had member transferred by ambulance to the hospital
Impact
- Prompt evaluation and coordination among Care360° Solutions team and PCP prevented development of potentially serious complications had member’s care been delayed
Case Example
Averting Anxiety
Situation
- VNSNY Care360° Solutions Care Manager heard anxiety in newly-enrolled member’s voice during a call. Member told him she was worried because delivery of her oxygen compressor was late and she was unable to reach a representative of that company
Customized Interventions
- Care Manager contacted the equipment vendor directly and arranged for oxygen compressor to arrive at member’s home that same day
- Care Manager followed up with a call to member that evening to confirm that the equipment had been delivered
Impact
- Care Manager’s proactive assistance ensured that member had the vital equipment needed to keep her safe and healthy at home
- Member’s anxiety was reduced due to VNSNY’s attentive and timely support
Case Example
Telemedicine Triage
Situation
- VNSNY Care360° Solutions nurse practitioner (NP) receives alert via telehealth about member in her 90s with multiple chronic conditions presenting with low-grade fever and shortness of breath
Customized Interventions
- VNSNY Care360° NP immediately triages member telephonically, assessing for conditions, including COVID-19, sepsis, and adverse drug reaction
- Given member’s age, underlying conditions, and symptoms, NP taps into VNSNY’s collaboration with Community Paramedicine to deploy clinician to member’s home
- NP and paramedic consult via phone; determine member is stable, does not need ED transfer, and can remain safely at home; likely cause of symptoms is allergy to a newly prescribed antibiotic for UTI
- NP coordinates with member’s PCP and pharmacy to obtain Rx for new antibiotic, and update member’s list of allergies
Impact
- Member was assessed and symptoms managed safely at home
- Avoided potential ER visit and possible exposure to COVID-19
- Information shared across care team members to avoid future antibiotic reaction
Case Example
Asthma Alert
Situation
- Member with severe asthma comes under the care of the VNSNY Care360° Solutions team
- Remote monitoring technology set up in member’s home
- Within a few weeks, the VNSNY Care360° Solutions team receives real-time alerts indicating abnormal drops in member’s blood oxygen levels
Customized Interventions
- VNSNY Care360° Solutions Care Manager promptly contacts member and learns she is self-medicating asthma with cough medicine
- Nurse Practitioner is engaged to educate member and provide coaching on proper use of rescue inhalers instead of cough medicine for symptom relief
Impact
- Member learns effective self-care techniques
- Avoided asthma exacerbation
- Prevented potential emergency room visit
Case Example
Diabetes Dilemma
Situation
- Member with multiple comorbidities including diabetes, chronic kidney disease, and heart failure reports low blood sugar measurement to VNSNY Care360° Solutions Care Manager, noting that she had been in bed all day
Customized Interventions
- Care Manager engages Nurse Practitioner (NP) and reviews member’s medications
- NP initiates a consult with member’s Primary Care Physician (PCP) via a three-way conference call
- PCP, NP, and member discuss appropriate adjustments to current diabetes medication regimen
- NP follows up with member to educate on medication action plan for avoiding medications known to lower blood sugar levels in specific situations
Impact
- Avoided serious hypoglycemic event and potential hospitalization or ED visit
- Successful physician engagement
Case Example
Summer Suffering
Situation
- Member with partially removed lung and COPD diagnosis is under care of VNSNY Care360⁰ Solutions
- During a routine check-in, the VNSNY Care360⁰ Solutions Care Manager notices member experiencing periodic shortness of breath
Customized Interventions
- After assessing the situation, it is determined that the extreme summer heat and poor apartment ventilation are likely exacerbating member’s condition
- Care Manager connects member to NYC’s Cooling Assistance program, which facilitated access to air conditioning unit
Impact
- Improved member outcomes by addressing key social determinants of health
- Member is able to manage through the summer remaining safe and comfortable at home
Case Example
A Rash Resolved
Situation
- Member experiences unusual, persistent, and painful rash over the course of several days
- Not wanting to go to the ED, but with their PCP out of town, the member alerts their VNSNY Care360⁰ Solutions Care Manager
Customized Interventions
- VNSNY Care360⁰ Solutions Nurse Practitioner (NP) quickly deployed to evaluate rash, provide a prescription, and teach proper rash care
- NP links member to a home visiting-MD practice for follow-up
Impact
- Improved quality of life through symptom management and increased comfort
- Avoided ED visit