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
Patient-Centric 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.

Category	Outcome
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 1^st 90 days
	Hospital days/1000 - 1^st 90 days
	Hospital days/1000 - first year
	% w/ catheter at 90 days
	Mean catheter days - first year
	Dialysis quality - 1^st 90 days
	% Home hemodialysis
	% Peritoneal dialysis

Category	Outcome
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
Pt. Activation	PAM score