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3 Embedded Care Coordination Models Manage Diverse High-Risk, High-Cost Populations When it comes to coordinating care for its highest-risk, highest-cost individuals—whether patients in a medical home, the geriatric homebound or its own employees—Yale New Haven Health System (YNHHS) believes an onsite, embedded face-to-face approach will best position it for success in a value-based healthcare industry. The Connecticut-based health system shared its vision for managing patients across its continuum via three embedded care coordination models 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.
In the first model, livingwellCARES, RN care coordinators at YNHHS's four health system campuses work with its high-risk, high-cost health system employees and their adult dependents with chronic disease. "We help these employees access the care they need and identify their goals of care. We get under the surface a little bit to determine barriers to their being as healthy as they can be and manage them over time," explained Amanda Skinner, executive director, clinical integration and population health, adding that YNHHS offers employees incentives such as waived insurance co-pays for participation. Launched three years ago, livingwellCARES was YNHHS's "on-the-job training for learning to manage care across the continuum," she continued. Starting with employees with diabetes, livingwellCARES expanded to care coordination of most chronic diseases. Having significantly impacted clinical metrics like A1Cs as well as hospital utilization and ED visits in the approximately 500 employees it manages, livingwellCARES is now transitioning to a more risk-based approach. The second embedded care coordination model, a patient-centered medical home (PCMH), also launched three years ago. Focused on complex care management, the PCMH is heavily driven by data derived from its electronic health records and patient registries, Ms. Skinner continued. Because five of eight PCMH care coordinators are embedded and cover multiple physician practices, YNHHS is exploring the use of televisits by care coordinators to manage patients in the practices served. Also important is schooling PCMH staff in the relatively new practice of "warm handovers" during critical transitions of care. Nine challenges of the PCMH embedded model shared by Ms. Skinner include engaging patients and obtaining reimbursement for various pay for performance programs. In the third model, outpatient geriatric care coordination, embedded high touch care coordinators manage frail elderly deemed homebound by Medicare standards—when it's a severe and taxing effort to leave the home—and those in assisted living facilities, explained Dr. Vivian Argento, executive director of geriatric and palliative services at Bridgeport Hospital. "There is a challenge not just with frailty but also with access—having these patients go into the physician offices—so that the care tends to get shifted into the hospital because it's easier for those patients to get there," Dr. Argento explained. Physicians and nurse practitioners provide care in the patient's home to break that utilization cycle, while embedded care coordinators constantly collaborate with the care team to risk-stratify and prioritize patients, resolve medication concerns, make referrals, manage care transitions, triage telephone calls—all tasks required to coordinate care for what Dr. Argento termed "a very sick Medicare population in in the last two to three years of life." Well received by the geriatric patients, the program also has positively impacted healthcare utilization metrics: its annual hospital admission rate of 5.4-5.8 percent is significantly below Medicare's overall 28-30 percent hospitalization rate, and the program boasts a readmissions rate of 14 percent, versus Medicare's 20 percent national average, Dr. Argento added. In case you missed this webinar, you still have a chance to watch this highly-rated program. Register to view the conference today or order your training DVD or CD: 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. It's so convenient! Invite your staff members to watch the conference. We will send you a DVD or CD-ROM of the conference proceedings or a link to our web site with a username and password. You can log in and view the program right from your computer — any time of the day or night, whenever convenient for you and your colleagues — and benefit from the archived recording of the conference, including the Q&A period. 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. To register for the on-demand re-broadcast, download an .MP3 file or order the training DVD or CD-ROM of Embedded Care Coordination for At-Risk Populations: A Case Study from Yale New Haven Health System, please visit: You may also be interested in these embedded case management resources:
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