Collaboration with VAAACares reduces hospital readmissions in Virginia

Hospital readmissions after the 30-day mark may indicate ineffective follow-up care or ineffective treatment prior to discharge.¹ Hospital readmissions rates are therefore often used as a measure of the quality of hospital care. Virginia has a 9.6% average 30-day readmission rate for 2017-2019, which is 2.2% higher than the national average.²

Committed to reducing health disparities, UnitedHealthcare Community Plan of Virginia has collaborated with VAAACares since 2018 to support members experiencing care transitions. VAAACares is a statewide Community Care Hub that develops and maintains a network of community-based organizations (CBOs) with centralized administrative and operational infrastructure.³ It provides care coordination and delivers evidence-based care transitions. Community Care Hubs are entities that support CBOs in providing services to address social needs that can affect health outcomes.⁴

VAAACares is headquartered within Bay Aging, a nonprofit with extensive experience in care coordination, health screening and care transitions in Virginia. The Care Hub is nationally recognized for the development of aging programs and services as well as approaches to address health-related social needs (HRSNs).

HRSNs are social and economic needs that affect individuals’ ability to maintain their health and well-being.⁵ Examples include employment, affordable and stable housing, access to nutrition and transportation. By targeting HSRNs, Community Care Hubs aim to reduce health disparities and promote equitable care.

UnitedHealthcare’s collaboration with VAAACares has had promising results. Between February and July 2023, VAAACares successfully engaged over 2,000 Commonwealth Coordinated Care Plus members, completing home visits and assessments for more than 90% of engaged members. Less than 13% of those members had a hospital readmission within 30 days.

Member impact

Recently, a UnitedHealthcare Community Plan of Virginia member was admitted to a Virginia hospital with a diagnosis of unstable angina. The patient presented with HSRNs of housing and medical care, as he was homeless and required further explanation of his treatment plan. After being discharged, the patient’s designated health coach located him living in his car with an outside temperature of below 10 degrees Fahrenheit. The health coach provided the patient with community resources, shelter information and an overview of his treatment plan and ensured the patient had food, medications and a scheduled follow-up appointment. The patient was able to obtain subsidized housing within three days and has been adhering to his treatment plan.

Care management extenders model

The collaboration will be expanding to support care management functions through a care management “extenders” model to identify the most urgent opportunities to support members across the Commonwealth. High-priority members include maternal and NICU members, those with a serious mental illness or primary behavioral health diagnosis (specifically in Southwest Virginia) and members receiving long-term services and supports (LTSS) waiver services (specifically in Northern Virginia).

VAAACares “extenders” will provide support with non-clinical tasks including behavioral health admissions follow-ups, monitoring and closing referrals and addressing health-related social needs. Extenders will be supervised by care managers and located in the same geographic regions as the members they serve. The Community Care Hub will additionally support the completion of other key activities, including:

• Completing Health Risk Assessments and screenings for Specialty High Priority Population members
• Providing outreach and assistance to UnitedHealthcare’s members including those who are visually impaired and/or hard of hearing who must take action to maintain their healthcare coverage

Extender roles will be available within maternal and infant care, LTSS care and behavioral health care. UnitedHealthcare Community Plan of Virginia and VAAACares will leverage joint experience from this expanded collaboration to increase the scope of services for the member populations.