- Proven strategy to increase chronic care coordination in rural, medically underserved areas throughout Virginia
- Use of care coordination teams to offer Medicare patients the tools they need to meaningfully engage with healthcare providers
- Effectively utilize primary care providers to meet the goals of maximizing healthcare outcomes for Medicare patients living with chronic illnesses
- Blends an extensive portfolio of services for long-term care and
community supports with pre– and post-acute care, and prevention activities that include the social model of evidence-based intervention
- Delivers supportive services that include transportation, home delivered meals, emergency medication purchase assistance and connections to other home and community programs
- Demonstrates continued positive trend toward further readmission rate reductions resulting in lower healthcare costs
- Virginia leader in demonstrating that by providing chronic disease self-management education, advance care planning, streamlining care coordination,utilizing prevention practices and other evidence-based programs, Virginians will receive quality healthcare outcomes with lower healthcare costs