This pragmatic clinical trial embedded in an accountable care organization will determine the comparative effectiveness of two approaches for assigning care coordinators to older adults at risk for cardiovascular outcomes. The hypothesis is that assigning care coordinators to older adults based on perceived need will be more effective at preventing emergency department visits and hospitalizations compared to usual care.
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Number of Emergency Department Visits or Hospital Admissions
Timeframe: Over 12 months (beginning 1 month after the start of care coordination)