Yale-New Haven Embedded High-Risk Care Coordinators Monitor Geriatric Homebound

Dr. Vivian ArgentoFollowing 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.

While the bulk of care provided by YNHHS’s geriatric care coordination model is delivered during house calls to seniors deemed homebound by Medicare criteria, the program also provides care to patients in assisted living facilities.

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.


Length: 3:11 minutes

Leave a Reply

Your email address will not be published. Required fields are marked *