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3 Embedded Care Coordination Models to Manage Diverse High-Risk, High-Cost Patients Across the Continuum
3 Embedded Care Coordination Models to Manage Diverse High-Risk, High-Cost Patients Across the Continuum
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Yale New Haven Health System (YNHHS) takes an on-site, embedded face-to-face approach to coordinating care for its highest-risk, highest-cost patients—whether identified within its own employee population, inside a patient-centered medical home (PCMH), or among the geriatric homebound. The Connecticut-based health system believes this vision of care management is the most direct path to success in a value-based healthcare industry.

3 Embedded Care Coordination Models to Manage Diverse High-Risk, High-Cost Patients Across the Continuum examines YNHHS's three models of embedded care coordination that deliver value while managing care across time, across people, and across the entire continuum of care.

In this 30-page resource, Amanda Skinner, executive director for clinical integration and population health at Yale New Haven Health System, and Dr. Vivian Argento, executive director for geriatric and palliative care services at Bridgeport Hospital, present a trio of on-site care models crafted by YNHHS to manage three distinct populations: its own health system employees and their high-risk dependents; patients in its employed physician organization; and the frail elderly in a geriatric care coordination effort.

Ms. Skinner and Dr. Argento cover the following concepts in this report:

  • Program details, clinical outcomes and results from the first embedded care coordination model, livingwellCARES, developed for YNHHS employees and their dependents, which served as a pilot for managing care across the continuum;
  • The YNHHS multi-faceted philosophy for employee population health that encompasses an on-site farmers' market, employee health programs and other services;
  • The focus, challenges and results from the second embedded care coordination model, a patient-centered medical home;
  • Contributions and required training of care managers and health coaches within the PCMH;
  • Responsibilities, huddles, post-visit management and outcomes of the final embedded care coordination model, an outpatient geriatric care coordination that is a high-touch approach for the frail elderly;
  • Risk stratification, care planning and transition management for the geriatric population;
  • Platforms and technologies supporting the three on-site care coordination models, including early results from telehealth;
  • Challenges, lessons learned and future plans for the three embedded care coordination models.
and much more.

Table of Contents

  • Embedded Care Coordination for At-Risk Populations: A Case Study from Yale New Haven Health System
    • Overview of Yale-New Haven Health System
    • Mission, Vision, Values and Strategy
    • Embedded Care Coordination Model 1: livingwellCARES
    • Onsite Face-to-Face Care Management for High-Risk, High-Cost Patients
    • Results and Clinical Outcomes from livingwellCARES
    • Embedded Care Coordination Model 2: Patient-Centered Medical Home
    • Focus of PCMH Care Management
    • PCMH Care Coordination Challenges
    • PCMH Results and Clinical Outcomes
    • Embedded Care Coordination Model 3: Outpatient Geriatric Care Coordination
    • Geriatric Care Coordination Model and Responsibilities
    • 3 Levels of Care Coordination Huddles
    • Components of Geriatric Care
    • Post-Visit Care Coordination
    • Results from Geriatric Care Coordination
  • Q&A: Ask the Experts
    • Care Delivery via Telehealth
    • Managing Dually Eligible and Low Health Literacy Patients
    • Reducing Patient No-Show Rates
    • Improving SNF Care Transitions
    • Snapshot Management
    • Remote Monitoring Strategies
    • Defining RN and LPN Roles
    • Integration of Behavioral Health and Primary Care
    • Advance Care Planning in Geriatric Care Coordination
    • Incentives for Creating Culture of Health
  • Glossary
  • For More Information
  • About the Contributors
Publication Date: March 2016
Number of Pages: 30
ISBN 10: 1-943542-06-6 (Print version); 1-943542-07-4 (PDF version)
ISBN 13: 978-1-943542-06-2 (Print version); 978-1-943542-07-9 (PDF version)
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