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.
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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:
and much more.
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;
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