We deploy a team of clinical experts led by physicians and supported by: nurse practitioners’ pharmacists, behavioralists, and dieticians, who collectively address patient medical, mental health, and lifestyle needs in a home-based environment to better manage patient health. Plus, providers offer urgent care visits and well-visits to help avoid hospitalizations and unnecessary costs -- benefits for all. Imagine patient readmissions dropping by 30%*.
* Over a period of 3 months prior to and 3 months following our engagement (Village@Home 2017 results).
Village establishes a patient baseline to identify gaps in care, appropriately documents the patient’s disease burden and improves HCC coding accuracy while readjusting risks that have previously been inappropriately documented. And it works. From 2016 to 2017, 87% of participating patients saw an improvement in their HCC risk score accuracy, while significantly increasing the number of patient touchpoints to address their clinical and behavioral needs, whether at home, in the doctor’s office, or at any other site of care.
Clinicians manage and intervene in chronic conditions to reduce unnecessary and costly medical services or hospitalizations through specialized education and training to help patients manage their illnesses in their homes. Patients are managed under value-based arrangements for 30, 60, and 90-day episodes of care. Village@Home is designed to adapt to patient clinical needs over time by closely following the progression of medical conditions and efficiently managing Transitions in Care to improve care and reduce costs. Combined with Village@Home’s proprietary-primary care home-based model, providers can also reduce re-admissions while increasing patient satisfaction. All measures critical in managing HEDIS and star ratings.
Once our patients are managed by a dedicated care team, trust builds, the patient experience is greatly enhanced, and treatment adherence and improved outcomes are the net result. Patient, caregiver, and primary care team are engaged collaboratively to implement coordinated, individualized plans that improve clinical outcomes and affordability. Thus Village@Home patients experience a 50% reduction in acute admissions and a significant savings in total cost of care.*
* Village@Home 2017 results
We primarily enter into a comprehensive value-based arrangement for all services but will explore individual service offerings with At-Risk Provider groups or Health plans.