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Clinical and Financial Outcomes

VillageHealth strives to reduce costs.

VillageHealth strives to achieve return on investment (ROI) within the first year of operation, and has achieved ROI of greater than 2.0 for some clients. We offer flexible contracting options to tailor a plan to your specific needs.

ICM Component

Improved Process of Care

Clinical / Service Benefit

Facility-Based Integrated Care Delivery 

  • Maximize benefit of facility’s multi-disciplinary team and access to patient
    • Pharmacy distribution
    • Immunizations
    • Patient education, coaching
    • Vascular access center
  • Improved compliance with care plan
  • Convenience and familiarity of care setting
  • Expansion of relationship with trusted provider
  • Increased confidence for self-care


Nurse Coaching

  • Complete patient assessment
  • Individualized care plan based on patient needs and evidence-based interventions
  • Face-to-face and telephonic coaching
  • Customized care plans to meet members’ unique goals
  • 24x7 access to expert resources
  • Trusted support and guidance for behavior change
  • Increased confidence for self-care
  • Pre-dialysis counseling
    • Face-to-face peer group and/or individual sessions
    • Referral to nephrologist
  • Lifestyle changes needed to slow disease progression
  • Informed decisions regarding start of dialysis (e.g. fistula, modality)
  • Co-morbid condition management
    • HbA1c testing
    • Diabetic retinopathy, podiatry
    • LDL testing
    • Lifestyle changes, e.g. diet
    • Referral for depression
  • Holistic nursing support for all conditions
  • Improved ability to provide self-care specific to conditions
  • Vascular access management
  • Rigorous seven-step process
  • Confidence to move to fistula
  • Support through multi-step catheter removal process
  • Improved access à optimal dialysis
  • Reduced infections
  • Medication therapy management
    • Systematic med reviews
    • Post-hospitalization med reconciliation
  • Avoided adverse drug interactions and adverse drug reactions
  • Reduced dosing errors
  • Reduced therapeutic duplication
  • Oral nutritional supplements
  • Increased albumin levels
  • Advanced care planning
  • Completion of advanced care plans / living wills
  • Counseling on end-of-life options
  • Better prepared to handle End of Life (EOL) decisions
  • Development of EOL wishes
  • Communication with family regarding EOL wishes

Care coordination

  • Multi-disciplinary patient care conferences
  • Multi-party plan for CVC removal
  • Post-discharge transition of care plan for hospitalizations
  • Compliance with needed specialist appointments
  • Alignment to common care plan
  • Seamless patient experience
  • Providers knowledgeable and informed of patient needs
  • Improved access to providers and compliance with care plan
  • Help understanding doctors orders

Remote monitoring

  • Real-time alerts on changes in health data – linked to clinical decision support systems
  • Real-time response capability
  • 24x7 knowledgeable support
  • Daily engagement with delivery system and care plan

Electronic data exchange

  • Providers fully informed of patients’ condition, treatment, encounter and episode history
  • Critical enabler for care management and care coordination interventions
  • Seamless patient experience leads to satisfaction and security
  • Reduced errors and duplication of testing and treatments

Mobile messaging

  • More frequent communication between patients and providers
  • Easy, effective, secure, real-time form of communications with coach and providers
  • Alert/reminder system supports compliance with care plan

Service Intensity Metrics

Intermediate outcomes → process and clinical results that are correlated with lower utilization and cost.

CKD progression
% progression to dialysis
Mean time to dialysis start
Rate of eGFR decline
%managed by nephrologist
Transition to Dialysis
% starting dialysis with catheter
% starting dialysis emergently
% mortality in 1st 90 days
Hospital days/1000 - 1st 90 days
Hospital days/1000 - first year
% w/ catheter at 90 days
Mean catheter days - first year
Dialysis quality - 1st 90 days
% Home hemodialysis
% Peritoneal dialysis
Preventive Interventions
% with pneumovax last 5 years
% with influenza vaccination
End-of life
% with advanced care plan
Hospice days/1000
Managing Co-morbids
HEDIS measures for cholesterol
HEDIS measures for diabetes
HEDIS measures for hypertension
Vascular Access
Catheter rate
Mean catheter days
Medication Management
Overall MPR score
ACE/ARB utilization
Fluid Management
Fluid-related ER visits pmpy
Fluid-related admissions pmpy
Pt. Activation
PAM score

Success Stories

" I am a 53-year-old man living in Riverside, CA who had a kidney ... more "
" I am the caregiver for my wife who had a stroke and cannot talk very ... more "
" When I was in the hospital, my VillageHealth Nurse was my lifeline. ... more "
" The Key to Better Health gives me a place to go for information and ... more "
" I am a 62-year-old man who lives in San Bernardino, CA and I have ... more "
" I am a 60-year-old woman who lives in San Bernardino, CA and I have ... more "

I am a 56-year-old man who lives in San Bernardino, CA ... more "


The Key to Better Health helps me feel better. My ... more "


I was blessed the day Key to Better Health first ... more "


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