Care Coordination

At VNA Health Care, we have a patient-centered focus. The VNA Care Coordination team case managers are patient advocates who support you in receiving the health care you need. Your case manager works to make sure you are properly connected to all the services you are eligible to receive at VNA as well as making sure that you receive referrals as needed to external care providers. VNA case managers and your VNA care team can help you with:

  • Helping set up appointments with your VNA Health Care providers and making referrals to specialists for services not available at VNA based on a patient’s needs.
  • Work with your insurance company to authorize services
  • Understand Medicare/Medicaid/insurance coverage
  • Complete healthcare paperwork
  • Follow up to ensure your outside services are contributing to your healthcare goals

If you are a healthcare professional and need to follow up on a referral to VNA Health Care, please call (630) 526-7939, press 1 for English and then press 4 to be transferred to a care coordination nurse.
Records and referrals may be faxed to (630) 482-8185, ATTN: Case Management.

To visit one of VNA’s primary care providers, call VNA at (630) 892-4355 or schedule an appointment online.

VNA is your Certified Primary Care Medical Home

According to the Joint Commission, achieving PCMH certification shows your patients and their families you’re committed to putting them first. The goal is to improve health outcomes by:

  • Educating patients and encouraging them to self-manage their condition or disease.
  • Allowing patients to take an active and decision-making role in their care.
  • Giving patients increased access to their primary care provider and an interdisciplinary care team, including after-hour phone access.
  • Tracking and coordinating patients’ care with health information technology. VNA provides easy access to your medical record with MyVNA MyChart. You can easily contact your provider, schedule an appointment, or request a prescription refill.

Primary Care Medical Home (PCMH) is a philosophy of care based on the Agency for Healthcare Research and Quality’s (AHRQ) definition of a medical home, which includes these core functions and attributes:

  • Patient-centered care: Relationship-based care focuses on the whole person and understanding and respecting each patient’s needs, culture, values and preferences.
  • Comprehensive care: A team of providers (including physicians, nurse practitioners, nurses, pharmacists, nutritionists, dietitians, mental health workers, social workers and others) work to meet each patient’s physical and mental health care needs, including prevention and wellness, acute care and chronic care.
  • Superb access to care: Patients have access to services with shorter waiting times for urgent needs, enhanced in-person hours, around the clock telephone or electronic access to members of the care team and alternative methods of communication.
  • Systems-based approach to quality and safety: The organization uses evidence-based medicine and clinical decision support tools, engages in performance measurement and improvement, measures and responds to patient experiences and satisfaction, practices population health management, and publicly shares robust quality and safety data and improvement activities.
  • Coordinated care: Care is coordinated across the broader health care system, including specialty care and the provision of community and support services. This is particularly critical during transitions between sites of care.


Care Coordination for Transition of Patient Care

When you have an unplanned admission to an inpatient healthcare facility or you’re scheduled for a planned inpatient surgical procedure, our case managers and hospital liaisons can help with continuity of care. We have effective systems in place to create a seamless transition to VNA primary care services. Our goal is to help you move from one level of care to another as easily as possible.

We work with you, your caregiver (and any other participants concerned) to ensure you have everything you need at home for faster recovery. This acute care coordination includes scheduling follow-up appointments and making sure to transition prescription medications as needed. Simply put your case manager in conjunction with your VNA care provider will:

  • Help arrange the health services you need, like scheduling appointments with multiple providers and making sure you are able to keep them.
  • Providing Home Visits if you are unable to visit the clinic
  • Understand your health conditions to reduce risks of hospitalization and support your ability to care for yourself.
  • Establish complete communication and service coordination to provide timely care as you move out of the hospital or another inpatient facility.
  • Provide guidance before a scheduled procedure, or after you’ve been discharged for an unplanned admission.
  • Educate you about the importance of taking medications (i.e., how and when) as prescribed by the doctor.
  • Review and clarify your doctor’s recommendations regarding your treatment, care, diet, and exercise.


Care Coordination for Pregnant Women

At VNA Health Care, our primary care coordination efforts are designed to pay special attention to health care delivery for moms-to-be. We help pregnant women gain access to recommended high-quality prenatal care and deliver a healthy baby without complications. If you are expecting, we will provide you:

  • Personalized, 1-on-1 patient care with registered dietitians and nurses.
  • Referrals to prenatal classes
  • Services from experienced Doulas, Midwives, Obstetricians, and Women’s Health Practitioners
  • Help connect you to VNA and community resources based on your personal needs.
  • Referrals to other VNA programs such as Healthy Families, Family Case Management and WIC which include access breastfeeding or childbirth education classes and education


Care Coordination for Chronic Disease Management

If you suffer from asthma, diabetes, high blood pressure, or chronic disease, you will receive support based on how much care you need. Your dedicated VNA care coordinator will work with you to improve health care delivery with the sole purpose of enhancing the quality of your life. This involves providing you with:

  • Education and information related to your diagnosis and treatment.
  • Assistance with learning how to manage your symptoms and adopt a healthy lifestyle to prevent unnecessary ER visits.
  • Help understanding and obtaining the prescription medications you need.
  • Referrals to community resources and programs for additional support, such as better access to healthy foods and community workout classes.


Care Coordination for Complex Health Issues

Patients who have one or more chronic diseases or conditions, such as thyroid disease, chronic obstructive pulmonary disease (COPD), Alzheimer’s disease, dementia, mobility disorders, or depression and other mood disorders, often have complex health needs and benefit greatly from the assistance of a VNA case manager. We offer targeted outreach by expert care providers who specialize in managing complex patient health. Your VNA care team will support you by:

  • Understanding your specific condition and creating a care plan to improve quality of life.
  • Arranging transportation to-and-from medical appointments when necessary.
  • Setting up medical appointments when needed.
  • Managing your condition with the right treatments and prescription medications so your symptoms don’t get worse.
  • Providing assistance in assessing your eligibility for insurance and medical plan benefits. Depending upon family size and income, you may be eligible for discounted rates.
  • Providing home visits if you are unable to visit the clinic due to health or mobility issues.


Learn More About Our Multidisciplinary Care Coordination Services

VNA Health Care recognizes that a patient’s care, health, and well-being depend on more than medical services. Living your best life doesn’t just mean taking prescription medications or visiting the doctor – it also means being able to reach the doctor for timely appointments and having access to healthy food and safe housing.  To make that possible, our team of doctors, nurse practitioners, registered nurses, nutritionists, care coordinators, social workers, work closely in conjunction with each other around the clock to make sure you are receiving the services you need the most.

Whether you need someone to assist you with transportation or scheduling of your doctor’s appointments or you need support while dealing with a mental health issue, we are here for you. We will answer any questions you might have about your illness, and make a plan to help you and your family with your health goals. Your health care team to make sure you receive the best care possible, and connect you to the right community resources.

Make VNA your Primary Care Medical Home and start receiving the benefit of VNA’s comprehensive care coordination services. Call us at (630) 892-4355 or schedule an appointment online.