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Our Care Model

Through GenHealth, GAPN members can access a suite of population health services that support physicians during efforts to improve quality and lower costs.

Transitional Care

We aim to reduce hospital readmissions by using propitery software to identify hospitalized patients and ensuring they get appropriate follow-up appointments after discharge.

Care Team: Care Navigators and Registered Nurse Care Managers

Key Elements:

  • Primary care physician is notified of hospital admission
  • Patient is scheduled for a follow-up appointment with PCP within 7-14 days of discharge
  • Discharge summary and medication reconciliation are delivered to PCP prior to appointment
  • Patient is followed by transitional care staff for 30 days to address questions or concerns

 Care Coordination

We utilize a team of nurses and community health workers to support patients with chronic illness and help them avoid complications and hospitalization.

Care Team: Care Navigators and Registered Nurse Care Managers

Key Elements:

  • Uses predictive modeling techniques to identify patients who are on a trajectory for high utilization and costs
  • Supports patients with disease-specific self-management education to ensure medication and appointment adherence

 Quality Management

Our program looks to close gaps in care through an electronic system that captures key quality measures and identifies missing or out-of-range values.

Key Elements:

  • Provides reports for Quality Incentive Programs
  • Identifies missing or out-of-range measures
  • Care Coordination staff can proactively contact patients about needed services


Read more about our Care Model in action.