The Foundation of all VillageHealth® Programs
Our programs are built on our integrated model of care, a holistic approach to managing the unique needs of medically complex renal patients across the entire care team and continuum.
What sets our model of care apart from other chronic condition management tactics is our patient-centered approach, built on:
- Routine access to patients within dialysis centers
- Deep nephrologist relationships
- Two decades of renal expertise and care management innovations
We stay current with evidence-based practices and the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines and other national guidelines. By leveraging our unique position as a dialysis organization and integrated care provider, we are helping chronic kidney disease (CKD) and end stage renal disease (ESRD) patients lead healthier lives while improving clinical outcomes and total cost of care.
We are the country’s largest renal provider accredited by the National Committee for Quality Assurance (NCQA). For information about our Clinical Practice guidelines click here.
VillageHealth’s Model of Care
More About Our Capabilities
Predictive Analytics and Risk Stratification
Proprietary renal-specific risk stratification algorithms and predictive models identify patients for specific care management interventions. Custom models forecast CKD patients most likely to transition to dialysis and ESRD patients most likely to be hospitalized.
Renal-Specific Care Management Capabilities
VillageHealth® renal nurse care managers (RNs), nurse practitioners (NPs) and non-clinical care coordinators provide onsite and telephonic support for patients—ideally in dialysis centers where patients treat 12 to 15 hours each week. We also have 24x7 call centers in three different time zones to support our patients and caregivers. Our nurses and care coordinators use Capella, our proprietary renal technology platform, to advance patient care pathways and clinical protocols.
Our renal care pathways are customized based on a patient’s state of health and renal disease and care plan.
Multidisciplinary Care Team
VillageHealth RNs, along with NPs in some markets and programs, coordinate care across dialysis center care teams (clinic nurses, patient care technicians, dietitians and social workers), nephrologists, specialists, behavioral health providers, hospitals and pharmacists to manage the medical and psychosocial needs of enrolled patients. While telephonic care management is invaluable, physically integrating the team into each dialysis center—when scale permits—further optimizes program results.
Renal Technology Platform
Capella, our renal technology platform, integrates our CKD and ESRD-specific care pathways and clinical protocols, predictive analytics and risk stratification algorithms to enable our VillageHealth nurses and care coordinators to uniquely tailor care for each patient. The technology platform integrates with a mobile care team rounding tool and multiple clinical data sources and systems.
VillageHealth nurses work with nephrologists to establish and manage each patient’s care plan and provide monthly integrated care reports.
ESRD patients must have access to quality nephrologists, specialists and dialysis centers. We partner with existing provider networks to make sure our patients receive high quality, timely and coordinated care. We also encourage patients to use publicly reported quality data, such as The Centers for Medicare & Medicaid’s Five-Star Ratings, when selecting a dialysis center so they can choose a center that best meets their needs.
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