b'QUALITY OF CARE Embedded Care THNs Embedded Care Model improves quality of care with integrated, collaborative and convenient care focused on closing care gaps, addressing social determinants of health and connecting patients to community resources. An extension of traditional care management and care coordination services, THNs embedded care team offers patients a one-stop-shop for health support within primary care practices. By analyzing practice-level data, THN can identify which practices have patient populations who can benefit most from onsite support to access the care they need.Working with 142 providers at 24 practices, THNs registered nurses, pharmacists, social workers and care guides provided chronic care management and care coordination services to 28,017 high-risk patients. Often, these patients manage two or more chronic conditions that may be complicated by medication complexity or other factors. In addition, patients with severe or uncontrolled chronic conditions, such as congestive heart failure or diabetes, are at high risk for requiring emergency care. Continuum Care Plans Embedded care and other participating clinicians collaborate on comprehensive Continuum Care Plans stored within patient electronic medical records, like Epic and Care Everywhere. These ambulatory care plans serve as a roadmap to ensure continuity of patient care, which is especially important in case of hospital admittance.With a focus on preventative care and early intervention, THNs 16 nurse health advisors and 7 care guides scheduled and performed 18,065 annual wellness visits and served 33 practices and 142 providers practices in 2022. 8'