VBC Complete™: Integrated Care Management for ACOs and IDNs

Strengthen population health performance through coordinated disease management, clinical pharmacist-led medication management, and social-needs support—delivered by one multidisciplinary clinical team.

Schedule a Strategy Session Review Our Nephrology Results

Clinician discussing an integrated care strategy with older adult patients

Turn Fragmented Programs Into One Coordinated Care Strategy

ACOs and integrated delivery networks are expected to improve quality, reduce avoidable utilization, manage clinical risk, and deliver a better patient experience—often while coordinating multiple practices, service lines, technology platforms, and care-management vendors.

The problem is rarely a lack of data or individual programs. The problem is fragmentation.

When chronic disease management, care transitions, remote monitoring, medication reviews, quality-gap closure, and social-needs support operate in separate workflows, important information may not reach the right clinician at the right time. Patients receive disconnected calls. Medication concerns remain unresolved. Social barriers continue to undermine otherwise sound care plans. Clinical teams spend valuable time reconciling information instead of acting on it.

VBC Complete™ gives ACOs and IDNs a more unified model. PharmD Live works as an extension of participating providers, combining longitudinal disease management, clinical pharmacist-led medication management, social determinants of health support, and cross-setting care coordination within a single operating strategy.

Three Capabilities Embedded Across the Model

These are not separate add-ons. They are interconnected capabilities embedded across the patient’s care journey.

Disease Management

Patients receive condition-specific monitoring, education, care-plan support, preventive care-gap follow-up, and coordination across treating providers. The care approach is tailored to the patient’s diagnoses, risk level, recent utilization, and goals—not limited to a one-size-fits-all monthly call.

Clinical Pharmacist-Led Medication Management

Medication risk is a major driver of avoidable utilization, particularly among older adults and patients with multiple chronic conditions. PharmD Live’s clinical pharmacists review the complete medication regimen, reconcile medications across care settings, identify adherence barriers, evaluate safety and appropriateness, and make informed, guideline-driven recommendations to the prescriber. The prescriber reviews the recommendations and makes all prescribing and therapy-adjustment decisions.

Social Determinants of Health Support

Even the best clinical plan can fail when a patient cannot afford a medication, reach an appointment, obtain appropriate food, understand complicated instructions, use monitoring technology, or access caregiver support. PharmD Live identifies relevant social barriers and helps connect patients and care teams with appropriate resources and next steps.

A Flexible Portfolio of Integrated Care Programs

VBC Complete™ can incorporate the services that best match the organization’s population, contracts, and operating priorities:

Healthcare professional greeting an older adult patient in a medical clinic

Chronic Care Management

Longitudinal care planning and between-visit support for patients with multiple chronic conditions.

Transitional Care Management

Timely post-discharge outreach, medication reconciliation, follow-up coordination, and 30-day transition support.

Remote Patient Monitoring

Collection and clinical review of relevant physiologic data to support earlier identification of concerning trends.

Medication Therapy Management

Comprehensive medication review, medication-problem identification, adherence support, and prescriber recommendations.

Advanced Primary Care Management

Risk-aligned, team-based support for eligible Medicare populations.

Behavioral Health Integration

Screening, follow-up, and care coordination addressing behavioral health needs that affect chronic disease outcomes.

Annual Wellness Visits

Preventive care planning, risk assessment, and care-gap identification delivered through the appropriate clinical team.

HCC and RAF Support

Identification of documentation opportunities for accurate and complete representation of patient complexity, subject to provider validation.

Pharmacogenomics

Targeted pharmacogenomic review when clinically appropriate to inform medication-selection or dosing discussions.

Condition-Specific Care Programs

Focused support for heart failure, chronic kidney disease, diabetes, COPD and asthma, obesity, and complex multi-condition populations.

Programs may be implemented individually or as an integrated portfolio. The recommended design depends on the population, baseline performance, contract requirements, existing resources, and measurable opportunities for improvement.

Built for the Priorities ACOs and IDNs Are Accountable For

Lower Total Cost of Care

VBC Complete™ targets modifiable contributors to avoidable cost: poorly controlled chronic disease, medication-related problems, failed care transitions, gaps in follow-up, low adherence, and unresolved social barriers. The model prioritizes patients and interventions based on clinical risk and the opportunity to prevent avoidable escalation.

Reduce Avoidable Hospital and Emergency Department Utilization

Continuous patient engagement, post-discharge follow-up, medication reconciliation, remote monitoring, symptom surveillance, and timely escalation help participating providers identify risk earlier and intervene before a concern becomes a crisis.

Improve Quality Performance

The multidisciplinary team supports care-gap closure, medication adherence, disease control, preventive care, patient engagement, and documentation across measures relevant to Medicare Shared Savings Program ACOs, ACO REACH organizations, Medicare Advantage plans, and other value-based arrangements.

Strengthen Medication Safety and Adherence

Medication-related problems often sit at the intersection of multiple diagnoses, specialists, and transitions of care. Clinical pharmacist expertise brings focused attention to polypharmacy, duplication, interactions, dose appropriateness, side effects, access barriers, and medication understanding.

Improve Patient and Provider Experience

Patients receive a consistent point of support between office visits. Participating practices gain additional clinical capacity without having to independently recruit, train, and manage every component of a broad care-management workforce.

Clinician checking blood pressure for an older adult patient

Documented Results From a Nephrology Engagement

In a featured nephrology chronic care management engagement, PharmD Live’s care model delivered:

$8.6 millionin healthcare cost avoidance

$3.50returned for every $1 invested

+91Net Promoter Score

These results demonstrate what coordinated, medication-focused, patient-centered care can accomplish when it is aligned with the needs of a high-risk chronic disease population. Results vary based on population characteristics, baseline performance, enrollment, program scope, implementation, and contract design.

How PharmD Live Works With Your Organization

Population and Contract Assessment
We begin with your attributed population, clinical priorities, utilization patterns, quality measures, existing programs, and value-based contract requirements.
Program Design
Together, we define eligible populations, workflows, escalation pathways, provider communication standards, reporting requirements, enrollment strategy, and the mix of services most likely to address your performance priorities.
Clinical and Operational Alignment
PharmD Live aligns with participating practices, establishes agreed workflows, supports patient identification and enrollment, and prepares the multidisciplinary team to operate as an extension of the existing care environment.
Launch and Longitudinal Care
The team begins patient outreach and care delivery according to the approved program design. Medication findings and clinical concerns are communicated to authorized treating providers for review and action.
Performance Review and Optimization
Reporting can include enrollment, engagement, outreach, care-plan activity, medication findings, interventions, care-gap activity, patient experience, utilization, and other agreed indicators. The program is refined over time based on observed performance and organizational priorities.

Older adult using remote monitoring technology at home

Who VBC Complete™ Serves

Accountable Care Organizations

Support attributed populations with coordinated services targeting total cost of care, avoidable utilization, quality performance, medication adherence, patient engagement, and health equity.

Integrated Delivery Networks

Connect hospitals, employed and affiliated practices, specialists, post-acute transitions, and ambulatory care through a consistent patient-support and medication-management strategy.

Health Systems

Extend care beyond the facility, strengthen discharge transitions, support high-risk populations, and give outpatient clinicians greater visibility into post-discharge medication and disease-management needs.

Payers and Health Plans

Address adherence, medication risk, chronic disease control, utilization, Stars and HEDIS priorities, and member barriers through scalable virtual clinical support.

Frequently Asked Questions

How is VBC Complete™ different from hiring several care-management vendors?

VBC Complete™ connects disease management, medication management, social-needs support, care transitions, and patient engagement through one coordinated clinical model. This reduces duplicative outreach and helps participating providers receive a more complete view of patient needs and recommended actions.

Does PharmD Live prescribe medications or independently change therapy?

No. PharmD Live reviews the patient’s medication regimen and makes informed, guideline-driven recommendations to the prescriber. The prescriber evaluates those recommendations and makes all prescribing and therapy-adjustment decisions.

Can VBC Complete™ work with our existing EHR and care-management infrastructure?

Yes. PharmD Live is EHR-agnostic and designs workflows around the organization’s existing clinical and technology environment. The exact integration, access, documentation, and data-exchange approach is determined during implementation.

Can an ACO begin with one population or program?

Yes. Organizations may begin with a priority population—such as recently discharged patients, high-risk patients with multiple chronic conditions, or members with significant medication risk—and expand based on results and organizational readiness.

What results should an organization expect?

The program is designed to improve care coordination, medication safety and adherence, patient engagement, quality performance, and avoidable utilization. Actual results depend on the population, baseline performance, enrollment, implementation, provider participation, and program duration.

Build a More Connected Value-Based Care Strategy

If fragmented programs, medication risk, failed transitions, or limited clinical capacity are constraining performance, PharmD Live can help you build a more coordinated model around the outcomes your contracts require.

Schedule a VBC Strategy Session View the Nephrology Case Study