YNHHS' Embedded High-Risk Care Coordinators
Monitor Geriatric Homebound

Following weekly huddles with nurse practitioners, Yale New Haven Health System (YNHHS) geriatric care coordinators use a red-yellow-green system to prioritize care for its Medicare homebound patients, explains Dr. Vivian Argento, the executive director of geriatric and palliative services at Bridgeport Hospital, in this audio interview.

In this podcast interview, Dr. Argento describes how the bulk of care provided by YNHHS's geriatric care coordination model is delivered during house calls to seniors deemed homebound by Medicare criteria and how the program provides care to patients in assisted living facilities.

Length: 3:11 minutes

The YNHHS geriatric care coordination model was one of three embedded models of care presented during a June 2015 webinar, Embedded Care Coordination for At-Risk Populations: A Case Study from Yale New Haven Health System, now available for replay. During the program, Dr. Argento was joined by Amanda Skinner, YNHHS executive director for clinical integration and population health, who described livingwellCARES, embedded on-site care coordination for YNHHS employees; and its patient-centered medical home’s hybrid model of centralized and embedded care coordination resources.

You can "attend" this program right in your office and learn Yale New Haven Health System's vision for employee population health, strategies for creating a healthy work environment, outline for patient-centered planned care and care coordination challenges.

You'll get to listen to the question and answer session to hear the difference between coordinating care for Medicare and for Medicaid patients, strategies to improve patient "no shows" for follow-up appointments, outreach to SNF patients to improve this care transition, integrating behavioral health and primary care, advanced care planning by the physician, and much more.

Register for the on-demand rebroadcast today or order your training DVD or CD online today at:

You may also be interested in these embedded care management resources: