Fig. 1

Overview of new model of person-centered care Fig. 1a) The digital Comprehensive Geriatric Assessment (CGA) generates biopsychosocial metrics (20 shown from the General Physical Health and Wellness, Mental Health, and Dental categories, teleoapp.com). Metrics results displayed as color-coded lights based on high (red), medium (yellow) and low (green) risk. 1b) The CGA facilitates appropriate referral and assignment to critical health and social services based on triage metrics (1 = Case Management need, 2 = Medical Complexity, 3 = Oral Health Status, 4 = Depression risk) and further investigation by the care navigator. Possible referral pathways are shown. BSS = Basic Screening Survey