5 Things to Know About High Value Care

Jessica Moschella, senior vice president of high value care at UVM Health Network, leads our efforts to evolve care delivery and improve the health of our patients and communities. Her work focuses on building a high-value care model that incentivizes high quality care through strategic partnerships with payers, improving patient outcomes and affordability.  

1. We are helping patients avoid unnecessary hospital visits.  

By emphasizing primary and preventive care, we aim to keep our patients physically and mentally healthy, heading off health problems before they require more acute care. Team-based care is crucial, bringing together health coaches, dietitians, pharmacists, care managers and mental health professionals to make sure our patients get exactly the care they need, when and where they need it. 

For instance, if a patient has been hospitalized but no longer requires hospital-based care, we help them transition to a more appropriate place to continue their recovery, whether that be at home under the care of their primary care provider, their local community hospital, or a rehabilitation or skilled nursing facility. Our priority is simply to connect our patients with the right support so they can stay healthy and avoid readmission to the hospital or trips to the emergency department. 

2. Care management and team-based care help people better manage their health.  

More than 7,000 patients are enrolled in our care management program, which offers a variety of services to help people overcome challenges that get in the way of achieving their health goals. This could mean nutritional counseling, working with a patient to help them better understand their chronic disease or medications or connecting them with community resources and social support services. 

A recent survey conducted by our care management team showed that 92% of our patients feel they understand their health concerns better after working with care management.  

Stories like Jim’s experience with care management (below) and Staci’s work with our new diabetes program are examples of how care management works effectively for our patients.

3. By better understanding our patients, we can focus on proactive, preventive care.     

We cannot effectively treat our patients without insight into their individual care needs. 

Our social needs screening tool helps us better understand our patients' needs. This survey gives us insight into aspects of our patients’ lives that may prevent them from reaching better health, while helping us understand who would benefit from care management.

We direct approximately 700 patients a month to care management services based on the information we receive from our social needs screenings.  

Another way we help our patients is by engaging them in health screenings. Prevention is key and early detection of diseases like colon cancer is linked to better outcomes for our patients. Our primary care teams are committed to partnering with our patients to educate them about what screening tests are right for them and proactively reaching out to ensure these screenings are done at the appropriate time.

4. We are working to shift more care to lower-cost settings and resources.  

Taking a proactive approach and providing care in the right setting helps lower health care costs and leads to better health. That’s the idea behind UVM Cares — a new partnership with University of Vermont focused on keeping people healthy, preventing hospital visits, managing chronic conditions and making health care easier to navigate. For example, a health and wellness coach can help people manage high blood pressure and cholesterol before it turns into a serious heart problem. And mental health support at a primary care office can help prevent a crisis that might otherwise need hospital care. Whatever the case may be, in the long run, these are resources that help keep our patients healthier, while providing care in the most appropriate setting. This costs less for everyone involved in the long run. 

5. We are always looking for ways to innovate and use technology to improve care delivery.  

Another priority is strengthening our electronic medical record system so it works better for clinicians and supports care coordination. Newly developed reports quickly identify patients who need outreach, while other tools help with managing chronic disease and bringing leading-edge treatments to the bedside. Continuously improving telehealth and MyChart – our digital patient portal available on our website or through an app – provides convenient access to the health care information our patients need. 

Do you have a better understanding of high value care? Ideas for how we can better tell this story? Please share your feedback through this form.