Population Health

Population health strategies allow Vaya Health to improve whole-person health outcomes for our members while streamlining and enhancing care management. The term population health encompasses:

  • The distribution of health outcomes within a population
  • The range of personal, social, economic and environmental factors that influence the distribution of health outcomes
  • The policies and interventions that affect those factors

The principles of population health impact both our daily operations and goals for the future. We believe integrated behavioral and physical healthcare produces the best results for our members and their health. Through Vaya Total Care, our complex care management model, we promote a team-based approach to integrated care that facilitates better communication among providers, generates robust data on outcomes and prepares Vaya to move forward as North Carolina reforms its Medicaid service management model as described in its Section 1115 Medicaid Demonstration Waiver Application.

Waiver goals include both advancing integrated care and improving population health statewide. Specialized behavioral health and intellectual/developmental disability (IDD) tailored plans include required use of the state’s health information exchange, as well as risk stratification and predictive modeling regarding care management needs. Additional plan components include the ability to aggregate encounter and care management data across providers for the purposes of population health management, quality improvement and reporting to the state and care management agencies.

Population health strategies prescribe different types of care management and member outreach based on a member’s health risk level. For example, members at high risk may need active case and disease management, while members at low risk may benefit from member outreach and engagement for preventative services.

Learn more about Medicaid Transformation on the N.C. Department of Health and Human Services (DHHS) website.

The care management continuum and you

Multiple Vaya departments and teams use population health strategies to produce a robust continuum of care management. These include:

  • Complex Care Management (formerly Care Coordination): Vaya care managers, formerly known as care coordinators, help link members to both services and community supports and resources to enhance mental and physical wellbeing and monitor individual progress. They also coordinate care for members with more complex care needs and N.C. Innovations participants.
    • The Transitions to Community Living Initiative (TCLI) gives eligible adults living with serious mental illness or severe and persistent mental illness the opportunity to choose where they live and work. Learn more.
    • Geriatric and Adult Mental Health Specialty Team: This team serves professional staff, family caregivers and other individuals who care for or work with older adults experiencing dementia or other behavioral health concerns. To refer a caregiver to the program, please complete the Geriatric and Adult Mental Health Specialty Team Referral Form.
  • Member Services: Our Member Services staff connect individuals to services and appropriate resources. The department also conducts member outreach and promotes engagement in care management functions.
  • Utilization Management (UM): Our UM Department ensures members receive the right services, at the right time, in the right amount.
  • Management Information Systems (MIS): We employ data analysts who specialize in identifying trends, tracking member outcomes and identifying needs within multiple populations.

Network providers are central to Vaya’s population health strategies and care management functions. We depend on you to provide needed services and supports, complete assessments to determine an individual’s appropriate level of care, monitor outcomes and provide other information we need to ensure the best whole-person health outcomes for the people we mutually serve.

Need Help?

Finding care can be confusing sometimes. At Vaya Health, we make it easier. The process starts with a phone call to our Access to Care Line at