The Senior Health & Wellness Center model aims to enhance coordination and continuity along the continuum of care, including outpatient primary care, inpatient acute care, skilled nursing facility care, and skilled home care. 

The HART (Health Assessment and Risk Test) screen will be used to identify two groups of elderly patients: well or low-risk elderly and frail or high-risk elderly. Moderate or high risk patients and their caregivers will be invited to participate with the team in developing care plans that include specific self-management and behavioral goals. Software application tools will be used for tracking, monitoring, and visit planning.