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Population Health and Care
Management

Care Management Solutions

Using VNSNY’s population health evidenced-based practices
and tools, our care team provides value-based care programs
and services for patients and members of hospitals, ACO’s
and health plans at all levels of risk. This proactive, person-
centered care approach addresses a spectrum of medical,
behavioral and social needs to reduce overall costs of care.
Our interdisciplinary team includes care managers (RNs,
PTs, OTs, LCSWs); nurse practitioners; health and wellness
coaches; pharmacists; transitional care associates; and
registered dieticians. Together, they:
• Employ extensive experience on managing chronic
conditions and comorbidities
• Focus on 30-60 day post-discharge and high-risk
populations
• Use clinical and non-clinical resources and interventions
• Facilitate in-person interventions, including Community
Paramedicine
• Coordinate care between providers and settings
• Facilitate patient education and coaching
• Utilize remote monitoring including voice response
and virtual visit technology
• Advocate for timely sharing of data through technology
• Use telephonic interventions for appointment reminders
and connections to community-based resources
• Engage patients in end-of-life conversations
• Perform gaps in care management and HEDIS reporting
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