Under the direction of the primary care physician, Nurse Care Managers, Resource Coordinators, Patient Care Coordinators, disease educators and pharmacists work in the practice to coordinate care and help patients with chronic health conditions face-to-face. Care plans are aligned to the patient's treatment plan, and teams are aligned with practice staff for overall coordination of care. These care teams play a critical role in helping the physician deliver higher quality care, such as higher medication adherence rates (96.4% for diabetes, 95.1% for hyperlipidemia, and 94.6% for hypertension) and hemoglobin A1c control rates 15% higher than the national average.
Patients receive custom care plans to meet their health, lifestyle, cultural and social needs. The focus is on total health, both physical and emotional, and overall wellbeing. Teams help patients understand their conditions, learn how to care for themselves at work and home, develop early-intervention strategies, remove barriers to adherence and get connected to additional providers and/or important health resources. This personalized support leads to an 11% higher rate of engagement for complex patients compared to market benchmarks.
Preventing issues before they arise leads to better outcomes than traditional programs that only react to acute events. The success of this preventive approach shows in the results: primary care providers supported by VillageMD have 20-45% lower admissions and readmission rates compared to market averages, and avoidable ED visits are more than 30% below average. Annual Wellness Visits provide an opportunity for physicians and patients to have a meaningful conversation about their health and deliver clinical information to help proactively identify patients in need. VillageMD's provider partners increased the number of Annual Wellness Visits by an average of 63%, gathering better health information on their patients for higher quality care.
In practices supported by VillageMD, 92% of all post-acute patients received a visit from either the primary care provider or a care manager shortly after discharge. With admissions, the transitional care management team begins planning before discharge to support patients at highest risk for readmission and set up a healthy transition home. The Village @Home program uses nurse practitioners to do check-ups at patients' homes, reconcile medications, help set up a safe home environment, and coordinate care with post-acute ancillary providers and specialists as needed.