VNSNY Care360⁰ Solutions Transitional Care Management focuses on members recently discharged from an acute care facility who are at high risk for readmissions.
Using evidence-based clinical and behavioral tools tailored for each member, we manage the medical, social, and behavioral conditions that influence post-acute recovery.
Over a defined time frame—60 to 90 days—our highly skilled care management team works collaboratively with your network partners to ensure the most appropriate care is provided in the right setting at the right time.
Target Population
Members recently discharged from an acute care facility who are at risk for readmission and/or extended skilled nursing facility (SNF) stays.
Benefits
- Manage conditions that influence post-acute recovery, including use of remote patient monitoring to help prevent condition exacerbation
- Decrease avoidable rehospitalizations and ED visits
- Achieve quality goals and HEDIS measures including PCP follow-up visits and medication adherence
- Reduce total cost of care through performance-based payment arrangements
Model of Care
VNSNY Care360° Solutions uses evidence-based, integrated clinical care activities tailored to effectively manage members’ medical, social, and behavioral health needs. Learn more about our model of care.
Demonstrated Outcomes
As a leader in providing care for vulnerable populations in the home and community, we leverage our local knowledge, population health best practices, and clinical expertise to have a significant impact on your members’ health. See examples of our excellent outcomes.
