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Disease Management

 Disease management

Kidney disease is a complex condition, and most patients need help to successfully manage it and its comorbidities. For nearly a decade before the term accountable care organizations (ACO) was coined, VillageHealthSM has provided integrated care management (ICM) services to improve the lives and clinical outcomes of kidney patients.

The VillageHealth team consists of specially trained, experienced nephrology nurses who develop, monitor and implement individualized care plans for each patient. VillageHealth nurses work with the patient’s nephrologist, dialysis center team, primary care physicians and others in the care team to develop, monitor and implement an individualized plan of care for the patient. They coordinate with the patient’s providers and help the patient overcome potential barriers to care by making appointments, arranging transportation, and other tasks. VillageHealth Nurses also coach the patient to greater self-care with proven, motivational interviewing approaches.

The ICM approach used by VillageHealth helps ensure that valuable healthcare resources are used effectively. It reduces avoidable hospitalizations due to factors like infection, medication errors and fluid overload. VillageHealth patients’ outcomes also include sharp decreases in catheter use and better medication adherence. 

VillageHealth provides ICM services to Medicare Advantage and Commercial health plans, encompassing more than 6,000 patients with chronic kidney disease (CKD) and end stage renal disease (ESRD).

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