Managed Long Term Care

 Bundles / Financing 
 Care Coordination 

Agency:
VNA of Central New York, Syracuse, New York.
 
Agency Description:
Visiting Nurse Association of Central New York, Inc. (VNA) was founded in 1890 with the mission of bringing professional health care to the home and teaching families how to care for their loved ones. Today, VNA continues this historic legacy by delivering an unprecedented level of care specifically designed to meet the needs of the patients. The focused approach of VNA improves the quality of each patient's life and helps each individual achieve maximum independence.

VNA Homecare was originally envisioned as a way of bringing the programs and services provided by Visiting Nurse Association of Central New York, Inc., CCH Home Care & Palliative Services, Inc., and Independent Health Care Services, Inc. together under one umbrella.

Since its inception, the system continues to embrace every opportunity to better meet the changing medical and non-medical needs of those throughout the region. Most recently, VNA Homecare launched VNA Homecare Options, LLC, a Managed Long Term Care (MLTC) Medicaid plan for those eligible for a nursing home level of care, added Home Aides of Central New York, Inc. to their system, and began operating an adult day program—all of which have been designed to enhance their range of offerings and develop a health care system that is unique and progressive.
 
Population Impacted:
Medicare and Medicaid-eligible beneficiaries with long-term care needs living in any of the 11 counties they are currently authorized to operate. VNA serves Onondaga, Cayuga, Chenango, Cortland, Jefferson, Madison, Oneida, Oswego, and Tompkins, all of which contain varying geographic densities. 
 
Strategic Partners:
VNA of Central New York is working with two independent practice associations (IPAs) in the delivery of care management services for members in counties serviced. The IPAs provide subcontracted care management services following the VNA's model of care.
 
Project Description:
Care managers work to ensure the correct services are provided at the proper time, enabling patients to live in the most independent setting possible.
Every patient is provided an MLTC care plan. Each MLTC plan is individualized based on the care needed. Care managers work closely with the patient’s primary care provider (PCP) to coordinate everything the patient needs in order to stay safe at home by using a wide array of specialty services in their network. This care plan is designed to accelerate recovery and maintain independence.
 
This program includes a strong focus on prevention and wellness promotion for patients. The focus is on proper utilization of services to maximize the member’s potential of self-care and independence. Strategies are implemented to empower members and families to take an active role in their care.
 
Results:
Increased use of preventive services, a noted reduction in complications, and less hospitalization overall.
 
Outcome Measures:
The VNA's MLTC hospitalization rate is significantly less than that of other MLTCs in the state. This is in large part to the model of care established for VNA patients. The graph below shows the state benchmark line in red and the blue line represents the number of patients in the program hospitalized at VNA.
 
Barriers to Implementation:
As a new program in some counties the VNA serves, physician providers often do not realize the value of this program or how it operates and are hesitant to join as a network provider or refer patients to the program.