Disease Management Programs Improve Adherence to Evidence-Based Processes and Outcomes by Targeting Sickest Patients and Working Closely With Physicians
A hospital-based outpatient disease management program serves patients with asthma, chronic heart failure, and diabetes and offers smoking cessation services to smokers. Unlike traditional disease management programs, this initiative heavily involves physicians in the initial referral and throughout the process and targets services toward the sickest patients (rather than to all patients with the condition).
Medical "Extensivists" Care for High-Acuity Patients Across Settings, Leading to Reduced Hospital Use
A Medicare Advantage plan uses employed "extensivists" who perform traditional hospitalist functions for a smaller-than-average caseload of patients, and then continue to follow and care for these patients after discharge until their condition becomes stabilized, leading to low length of stay and fewer readmissions.
Multidisciplinary Team, Real-Time Information, and Incentives Help Medical Homes Improve Mental Health and Patient Experience, Reduce Utilization and Costs
As part of a statewide public-private initiative, the diverse Burlington (Vermont) health service area supports 18 patient-centered medical home practices via a multidisciplinary team, real-time electronic information, and financial incentives, leading to more appropriate care, better health outcomes and patient experiences, and lower utilization and costs.
Placing Mental Health Specialists in Primary Care Settings Enhances Patient Engagement, Produces Favorable Results Relative to Evidence-Based Care
An integrated care program places mental and behavioral health specialists in more than 50 primary care locations to treat patients ages 65 years and older with depression or anxiety and those who engage in risky alcohol use.
Postdischarge Care Management Integrates Medical and Psychosocial Care of Low-Income Elderly Patients
An interdisciplinary care management program that integrates medical and social care for low-income elderly patients with chronic illnesses reduces care costs and improves self-reported health status.
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Health Information Exchange Toolkit
This toolkit is designed to assist health care leaders in managing the challenges associated with developing, adopting, operating, and sustaining a health information exchange.
Practice Facilitation Handbook: Training Modules for New Facilitators and Their Trainers
The Practice Facilitation Handbook is designed to assist in the training of new practice facilitators as they begin to develop the knowledge and skills needed to support meaningful improvement in primary care practices.
Integrating Chronic Care and Business Strategies in the Safety Net: A Practice Coaching Manual
This practice coaching manual and the companion toolkit, Integrating Chronic Care and Business Strategies in the Safety Net, provide the tools and structure for coaches to use in helping teams to improve clinical quality in a wide variety of settings.
Tools To Facilitate Diagnosis, Follow-Up, and Management of Postpartum Depression
This supplemental appendix for the Translating Research into Practice for Postpartum Depression (TRIPPD) effectiveness study provides a set of tools to facilitate diagnosis, follow-up, and management of postpartum depression.
Great Plains Telehealth Resource and Assistance Center Toolkit
This toolkit is for organizations starting or expanding a telehealth program at their facility.