Vaya Total Care (VTC) is Vaya Health’s complex care management model that offers a team-based approach to integrated healthcare. This model makes navigating the healthcare system easier for members while supporting collaboration among behavioral and physical health providers. Vaya care managers work closely with members, relatives, caregivers, social determinant support agencies, behavioral health and intellectual/developmental disability (IDD) service providers, primary care practices and other medical providers to identify the right services and to connect people with the care and support that they need.
VTC uses a customized version of the Incedo™ software system to produce a unified care plan tailored to our members’ specific needs. VTC is an administrative service offered at no cost to participating members or providers.
VTC is available to qualifying Vaya members who have complex healthcare needs and receive Medicaid or are uninsured. Vaya care managers (formerly called care coordinators) work to:
- Identify members who are eligible for complex care management through referrals and reports
- Complete a health risk assessment to identify areas where members may need support
- Develop a care plan with prioritized, whole-person goals and interventions
- Manage members’ services across the continuum of care and link members to appropriate treatment
- Ensure members receive appropriate clinical assessments and evaluations and have access to clinical and medical specialists
- Assist members who are at high risk for hospitalization or institutionalization
- Support members returning to the community who have been living in an institution, hospital or residential setting
- Check on the health and safety of N.C. Innovations participants
To refer a member for complex care management, please complete the Vaya Health Complex Care Management Referral Form.
Care coordination is administrative service defined by federal and state law and Vaya Health’s contracts with NC Medicaid and the N.C. Division of Mental Health, Developmental Disabilities and Substance Abuse Services (N.C. DMH/DD/SAS). We accept internal and external referrals for care coordination from any organization or individual (including members, caregivers, hospital discharge planners, the N.C. Division of Juvenile Justice, departments of Social Services, primary care and behavioral healthcare providers, disease management programs, utilization management programs, health information lines, etc.) using the Vaya Health Complex Care Management Referral Form.
When behavioral health and medical teams work together, members benefit. Better communication among providers means that members’ healthcare plans can address the many parts of their lives that help shape the recovery journey.
Members also tell us that they are more satisfied with the care that they receive when they know that their chosen providers are working together to support their healthcare goals.
VTC addresses health disparities, lack of integration across the health spectrum and poor engagement, as well as social determinants such as employment, housing and other barriers to accessing care. A comprehensive Health Risk Assessment (HRA), relevant screenings and risk stratification are used to develop a single care plan and coordinated interventions. The plan is customized to a member’s needs and shared across a multidisciplinary team through the VTC platform.
These efforts tackle common issues that frequently affect the wellbeing of members with complex healthcare needs. VTC makes it easier for members, who may be involved with a variety of social services agencies, to navigate multiple service systems and provider services to help avoid “falling through the cracks.” As North Carolina proceeds with Medicaid Transformation, VTC helps prepare Vaya, members and network providers for a smoother transition to integrated care and makes the best use of healthcare analytics to improve both member outcomes and management of Medicaid services under a capitated model.