VNS Health Total: Enhanced Disease Management

Disease management is a system of coordinated healthcare interventions and communications for people with conditions that require significant self-care efforts.  It is a broader, holistic, care management approach.  It differs from care management in that care management is tailored to the individual and focuses on a single person, whereas disease management is meant to help entire populations of people (particularly the 15%-25% of health plan members at high risk) using an integrated, multi-level approach. It delivers coordinated care in partnership with providers and a multidisciplinary care team of healthcare professionals.

Eligible members can take advantage of enhanced disease management services that include:

• Home visits by a nurse to evaluate health, social, and home safety needs

• Help to find doctors and make appointments

• Help taking medicine the right way, consistently and on time

• Connections to community resources

Typically nurses and social workers are heavily involved and serve as the point of contact between the member and the providers.  Other professionals such as registered dietitians may also participate.