CenVaNet

This program offers an integrated delivery system comprised of 10 not-for-profit hospitals and 900 community-based physicians. Its care managers are coordinated with the help of a user-friendly software platform that helps them identify potential problems and direct patients to appropriate healthcare providers, while providing evidence-based national treatment guidelines, medical information and other resources, making patients less likely to end up in the emergency room or be hospitalized, thus avoiding costly health complications in the future. CenVaNet has seven care managers (registered nurses and social workers), each treating between 50 and 70 patients, who provide in-home, telephonic and online care management focusing on four chronic diseases common in the Medicare population: congestive heart failure, chronic obstructive pulmonary disease, diabetes and asthma. To supplement care managers’ patient education efforts, the program offers other resources for patients to learn about their health, such as printed and electronic materials.

Through the care management software technology, patients can take advantage of a vast library of reliable health information and access patient tools designed to improve their care and increase their knowledge of their chronic conditions. This technology also addresses the problem of fragmentation of information. Care managers, physicians and patients are linked together by using the same software, increasing communication and improving the quality of care. This is further strengthened by automated interfaces that allow hospital labs, home care companies and others involved in a patient’s care to download information directly into our software platform. This eliminates the need for patients to recall which diagnostic tests they had performed and why. All of these capabilities are important steps in improving the care Medicare patients receive, and particularly benefit patients with multiple chronic conditions.