Care Coordination

The VAAACares Care Coordination program is accredited by NCQA and is designed to provide necessary services to promote the health, welfare, maintenance, protection and care to individuals in their living environments.

Services provided through care coordination include but not limited to:

  •  Monthly contacts: face-to-face & telephonic
  • Plan of care development
  • Health screening assessments
  • Authorization approvals
  • Comprehensive assessments
  • Level of Care Reassessments (LOCERI)
  • Interdisciplinary Care Team meetings
  • Repatriation of nursing facility members back to the community setting
  • Referrals to community resources to address social determinates of health (SDOH)
  • Caregiver support interventions

VAAACares provides care coordination to participants in accordance with their needs and goals to maintain the highest level of independent functioning. The care coordinator assesses the participant to determine needed service referrals for services or other community resources. The scope includes the following key functions in delivery of person-centered care to those individuals served:

  • Care Coordination to include referrals to community resources
  • Case management plan development, with person-centered goals
  • Nutrition services to include Meals on Wheels or congregate meals
  • Personal care assistance
  • Housekeeping and chore service (Homemaker/Personal assistance)
  • Transportation
  • Housing-related services
  • Advocacy
  • Risk assessment
  • Transitional Care
  • Performance measurement and continuous quality improvement

The overall goal in providing care coordination services is to help participants achieve an optimal level of health and well-being while living in their preferred setting. VAAACares Care Coordination program is an effective solution to the following:

  • To improve health status and quality of life by delivering quality care and services to participants through an integrated, comprehensive, and ongoing system of monitoring, evaluation, and improvement.
  • To reduce healthcare costs to the health system and participants by effectively and efficiently managing health benefits, hospitalizations, and promoting healthy lifestyles to prevent institutional placement.
  • To maintain high standards of care and service by employing experienced healthcare
    professionals, adopting, and implementing evidence-based standards of care.
  • To perform as a single multi-disciplinary team by creating a single focal point for each participant in which information is communicated resulting in care that is provided in a conscientious and cost-effective manner.
  • To improve participant satisfaction.

VAAACares is also assisting Virginia Medicaid plans with Commonwealth Coordinated Care Plus (CCC+) and Medallion 4.0 members as they merge into Cardinal Care, the universal Medicaid managed care program. Our experienced staff conduct outreach to members and complete health screenings, assessments, and assist members to access community resources.



Care Transitions

The VAAACares care transitions program provides techniques that promote patient and caregiver engagement to take an active role in their health care. Care transition interventions facilitate new behaviors and self-management strategies that promote successful responses to common health problems that occur after transitions between health care settings.
Services provided through care transitions:

  • Hospital visit
  • Home visit
  • Medication Management
  • Red flag identification
  • Follow-up phone calls
  • Referrals to other services including options counseling, transportation, meals/nutrition, personal care, respite and adult day health services

Add-on services:

  • Medication Reconciliation with RN review
  • Post Hospital Assessments
  • Remote Patient Monitoring Assistance
  • Chronic Disease Self-Management Classes
  • Diabetes Self-Management Classes

Evidence-Based Services

• Chronic Disease Self Management (CDSM)
• Diabetes Self Management
• Behavioral Health
• Fall Prevention
• Advance Care Planning
• Motivational Interviewing
• Patient Activation Measure (PAM)
• Telehealth

Patient Needs Met

• Housing Needs
• Adult Day Care
• Meals on Wheels
• In-Home Care Services
• Advance Care Planning
• In-depth Options Counseling
• Behavioral Health Screening
• Tele-education & Telehealth
• Transportation