Improving Health Care Access in the Rockaways and Staten Island
VNS Health’s initiatives in the Rockaways and Staten Island include many frontline team members who live
and work in these communities.
VNS Health has launched a pair of initiatives aimed at expanding its
presence and improving health care access in two underserved areas of New York City—the Rockaways, a barrier
island community on the southern edge of Queens, and the borough of Staten Island.
“These are communities with higher rates of chronic illness and less access to health care than other parts
of the city,” explains Gloria DiFeo, Director of Strategic Account Development for VNS Health. “Our
initiatives aim to address those gaps by increasing the footprint of our provider services and our health
plans in these neighborhoods.”
To support this effort, VNS Health has established a Strategic Action Group (SAG) in each of the two target
areas. These SAGs include representatives from VNS Health Home Care, Hospice, Personal Care and Health
Plans, many of them frontline team members who have lived and worked in these communities for years and are
personally connected to the neighborhoods.
In the Rockaways, where the organization’s health plans already have a neighborhood walk-in office, VNS
Health is now collaborating with JASA (Jewish Association Serving the Aging), which operates a retirement
complex with 1,000 seniors in the Rockaways, to bring additional VNS Health services to their clients. VNS
Health is also working closely with physicians in the community to make them aware of how VNS Health can
support their patient population, and has begun partnering with local skilled nursing facilities to provide
in-house hospice services as needed.
“As our activities in these communities expand, we’re growing the teams serving these areas through active
recruitment,” reports Rosin Rogers, a VNS Health account director who helps lead the Rockaways initiative.
“Our Home Care team, for example, recently hired a number of additional clinicians for their Rockaways
operations.”
To improve health care access and outcomes, VNS Health’s Provider Services and Health Plans are
expanding their presence in the Rockaways and other underserved communities.
The Staten Island SAG, which launched more recently, is currently focused on enhancing VNS Health’s
relationships with local care providers. “Staten Island’s demographics have been changing rapidly, resulting
in some gaps in care,” notes DiFeo. “The borough’s Asian population has increased substantially and now
constitutes 13% of its residents. This is a population that VNS Health has a long history of serving, so
we’re working now to hire additional Cantonese- and Mandarin-speaking nurses and rehabilitation therapists
for the area.”
Staten Island also has a large and growing geriatric population in need of home-based care, notes DiFeo, as
well as a number of veterans who could benefit from VNS Health’s Veterans Outreach Program (see story
below).
“The message we’re sending is that VNS Health offers one-stop shopping for Staten Islanders—from our health
plans to our home care, hospice care and home health aide services,” says DiFeo. “If you’re a Staten Island
physician or hospital, we have the bandwidth to take care of your patients at any point in their life.”
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VNS Health’s MAP Plan Rated #1 for Quality by New York State
VNS Health’s dual-eligible Medicaid Advantage Plus (MAP) plan, VNS
Health Total, has been ranked number one by New York State’s Department of Health (DOH) in its latest
Quality Incentive ratings. The ratings used various quality measures related to clinical quality, member
satisfaction and compliance to compare the performance of 44 MAP and Medicaid Managed Long Term Care (MLTC)
plans across New York.
VNS Health Total also received 5 Stars—the highest score possible—in DOH’s separate consumer-facing Stars
quality ratings, making it the only 5-Star MAP plan in the state. In addition, VNS Health’s stand-alone MLTC
plan, which provides Medicaid long-term care benefits without a Medicare component, received an impressive
4-Star rating from DOH in the state’s most recent Stars ratings.
VNS Health Total is the only 5-Star Medicaid Advantage Plus (MAP) plan in New York. VNS Health Total
also scored the highest Quality Incentive ratings of any MAP or MLTC plan in the state.
VNS Health Total brings together Medicare Advantage and Medicaid Managed Long Term Care (MLTC) benefits in a
single plan, and is designed for people who are eligible for both Medicare and Medicaid and need ongoing
assistance with activities of daily living in order to remain safe and independent in their homes. Currently
53,000 New Yorkers are enrolled in all MAP plans statewide. With DOH’s encouragement, that number is
expected to grow significantly in coming years.
“Dual-eligible MAP plans like VNS Health Total are critically important to helping New Yorkers with
long-term care needs live their best lives in their homes and communities,” says John Burke, VNS Health EVP
and Chief of Health Plans. “For decades, VNS Health has been at the forefront in developing health plans for
people with complex medical conditions. Today, we’re proud to be leading New York in offering high-quality
integrated health plans like VNS Health Total.”
VNS Health’s Medicaid MLTC plan is now available in 37 New York State counties, while their Medicare plans
(including VNS Health Total) are available in New York City’s five boroughs as well as Westchester, Nassau,
Suffolk, Albany, Schenectady and Rensselaer counties.
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Getting to “Yes” with Complex Patients
An interview with Brenda Riordan, who joined VNS Health this past July as Senior Vice President, Home Care and Care Management Solutions. In this one-on-one discussion, Riordan focuses on VNS Health’s Home Care team and its challenges and successes.
The home care industry is facing its share of challenges. How is VNS Health Home Care faring?
We’re doing well. Demand for home care is very high, which is a good problem to have—we’re getting plenty of
referrals. But we also need to make sure we have the capacity to meet this demand, so we’re working hard on
hiring and retention. We added a substantial number of new nurses to our Home Care team in 2024. At the same
time, our overall turnover rate has gone from 25 percent to 13 percent in the past year, which means we’re
retaining many more team members.
What’s contributed to this improvement?
We’re very committed to supporting our team members, in the field and otherwise, and it’s having a positive
effect. We established a task force dedicated to optimizing retention of Home Care team members, and we’ve
made a number of positive changes as a result—such as retooling how new clinicians are onboarded, so they
have more mentoring during their critical first year. Our team members also provide ongoing input through
various platforms that allow them to help shape our policies and procedures.
How is this strong hiring and retention impacting your Home Care admissions?
I’m pleased to say that our patient volume is the highest it’s been since the pandemic. At the moment we’re
focused on raising our conversion rate, which is the percentage of referrals we accept. As part of this
effort, we’ve begun evaluating our most challenging referrals on a case-by-case basis, seeing how we can get
to “yes” as far as admitting these complex patients, and our conversion rate is trending upward as a result.
What kind of care model does VNS Health offer complex patients?
What’s exciting to me is that VNS Health has all the components to deliver truly integrated care—home care,
home health aide services, hospice, behavioral health, care management, and in-home medical care. There are
very few organizations that bring together all of these different services. When it comes to delivering
integrated care and managing chronic conditions for vulnerable patient populations, VNS Health is very well
situated.
You started at VNS Health in July. What’s struck you so far about VNS Health as an organization?
One thing that comes through clearly is the longevity and dedication of the team members who work here. That
speaks volumes for the organization. I think the history of VNS Health and the commitment of our people is
second to none.
Is that what led you to join VNS Health?
That, and VNS Health’s mission. I wanted to get back to the mission-driven work of developing an integrated
care model in underserved communities—which is at the core of everything we do.
You’re an occupational therapist by training. How has that impacted your current role?
Occupational therapists are fundamentally problem solvers. It’s a key part of our training as OTs. From a
leadership perspective, that skill set is extremely useful when it comes to bringing people together and
working with them to overcome barriers and challenges as a team—which sums up my job pretty well!
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Hospices Across the U.S. to Start Using Hospice Predictive Model Developed by VNS Health
VNS Health’s technology team has developed a number of predictive models to improve patient outcomes,
including one that is now being incorporated into the electronic health record of Netsmart, a national
software company.
Earlier this year, Netsmart Technologies, an industry-leading software
company specializing in healthcare information technology, entered into an agreement with VNS Health to take
a predictive, algorithm-driven model developed by VNS Health’s technology team and integrate it into
Netsmart’s MyUnity electronic health record.
The predictive model assesses a hospice patient’s risk of dying over the next seven days, based on that
patient’s medical record. Hospice teams can then use this information to schedule additional visits to
patients who are at highest risk—ensuring that patients and families have the support they need during this
difficult time in the end-of-life journey.
Besides contributing to better patient outcomes and experience, the model also supports improved quality
scores on the CMS metric Hospice Visits in Last Days of Life (HVLDL) for hospice providers. After launching
the model internally, VNS Health Hospice improved its own HVLDL scores by 65%.
Now, as the model becomes available to Netsmart’s MyUnity customers, VNS Health’s technology will have an
opportunity to impact hospice patient outcomes on a national scale. Starting in spring of 2025, as a first
step in the roll-out, four of Netsmart’s hospice customers will have the technology incorporated into their
electronic health record platforms, bringing its benefits to over a thousand additional hospice patients.
This predictive analytics tool is just one of many that VNS Health’s technology team has developed to help
improve outcomes for hospice patients at the end of life. Other examples include a proprietary automated
model that hospice programs can use to predict a hospice patient’s length of stay, and another predictive
model, still in the development stage, that will allow care management organizations and insurers to
stratify the mortality risk of health plan members over the next 6 to 12 months.
“VNS Health is uniquely positioned to develop these types of predictive machine learning models,” notes Tim
Peng, VNS Health’s Executive Vice President of Science and Technology. “We have decades of data to draw on,
deep operational expertise, and we have on staff a highly talented technical team.”
In addition, notes Peng, being a home care and hospice provider, VNS Health can demonstrate the value of
these predictive models in a real-world setting. “We look forward to bringing more of our innovative
products to the marketplace going forward,” he adds, “where they can be adopted and utilized at scale by
other healthcare providers across the country.”
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In-Home COPD Care Aims to Prevent Unneeded Hospitalizations This Winter
VNS Health clinicians use a range of approaches to help people with COPD avoid unneeded
hospitalizations. These include remote monitoring of patients’ oxygen levels and education on how to
self-manage their condition at home.
It’s an all-too-common situation for people with advanced COPD (chronic
obstructive pulmonary disease): Winter arrives with its colder, dryer air, and their respiratory symptoms
take a turn for the worse. If these flare-ups aren’t managed effectively and it becomes too difficult for
them to breathe, the next step is often a trip to the hospital emergency department.
This scenario is exactly what VNS Health’s clinical COPD program is designed to prevent. “All the nurses
across our Home Care team, our Care Management Organization [CMO] and our Hospice program are highly skilled
at helping COPD patients and their family members self-manage their condition at home and avoid unnecessary
hospitalizations,” notes Roisin Rogers, a registered nurse and account director with VNS Health Home Care.
“Is the patient using their inhaler correctly and keeping it with them at all times? Are they taking their
medications as prescribed, and do they have regular medical follow-up visits scheduled? These are all issues
our nurses focus on.”
If COPD symptoms do crop up, adds Rogers, “we teach families what the symptoms mean and what the family
should do when they arise. We also connect families with COPD support services in the community.”
This advanced COPD expertise extends to VNS Health’s CMO nurse care managers, who oversee the care of health
plan members with complex conditions like COPD. The CMO offers remote monitoring of COPD patients, where
their oxygen levels and heart rate are tracked and automatically transmitted to VNS Health. The care
managers also check in with plan members regularly and can swiftly dispatch a nurse practitioner to the
member’s home if symptoms escalate.
Finally, if a patient’s condition progresses to the point where they decide to enter hospice care, VNS
Health Hospice provides specialized care for patients with a diagnosis of COPD.
Rogers works closely with VNS Health’s business development team and health care providers in the
community—including hospitals, clinics, physician offices and home visiting practices—to ensure that
patients with COPD and their families have access to VNS Health’s full range of COPD services. The business
development team also holds educational sessions at local senior centers, providing advice on COPD
management and making community members aware of VNS Health’s COPD expertise.
“We have the same goal across all our COPD protocols and educational activities,” adds Rogers. “We want to
make sure people with COPD are effectively cared for along a steady continuum, with smooth transitions and
no interruptions in care. This is the approach we’ve always followed at VNS Health: Once we’ve started
working with you, we continue with you throughout your health care journey, wherever that may lead.”
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VNS Health Spotlights Mental Health Challenges Facing Military Veterans
In addition to ensuring veterans get appropriate care and linking them to VA benefits, VNS Health’s
veteran liaisons often hold in-home ceremonies to honor a patient’s service.
Earlier this fall, the VNS Health Veterans Outreach Program hosted a
continuing education webinar for New York-area social workers and other clinicians, designed to enhance
their understanding of the mental health challenges facing military veterans. The webinar included a
presentation by Dr. Lauren D’Mello, Executive Director of Community Mental Health for New York City’s
Department of Veteran Services, followed by a panel discussion.
“The main focus of the webinar was to educate our provider partners in the community—particularly those who
work with veterans—on the unique mental health issues facing veterans,” explains Contessa Officer, Director
of the VNS Health Veterans Outreach Program. “At the same time, we’re making providers aware of our program
and how it can support their patients.”
As valuable as this type of community outreach is, Officer’s team spends the bulk of their time working
individually with veterans who have been admitted to programs across VNS Health, including Home Care,
Hospice, Personal Care, Care Management and Health Plans—in all, well over 1,000 veterans and their families
each year. The program is available to anyone who served in the military, and VNS Health clinicians are
encouraged to refer any eligible patient in their care.
“Our goal is to improve the overall quality of life for veterans and their families,” says Officer, who is a
military veteran herself. “That includes making sure veterans are getting the care they need, and connecting
them with all the veteran’s benefits due them.” Most veterans who enter VNS Health’s care have never applied
for VA benefits, she adds. “They and their families are often surprised at the many types of support
available to them, which can include financial assistance. Our team helps them navigate the VA system and
apply for these benefits.”
The Veterans Outreach Program also connects veterans to behavioral health care services and helps them and
their families link with other resources as well. In addition, as part of its community outreach, the
program cultivates relationships with a wide range of local organizations, including New York City’s
Department of Veteran Services and numerous community-based organizations that advocate for veterans.
“Anyone who works with veterans is a potential partner of ours,” says Officer. “We want everyone to know
that VNS Health is a veteran-centric organization, and that we’re here to help.”
*The patient’s name has been changed for privacy.
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