Multidisciplinary teams embedded within primary care practices provide care management and other support services to medically and psychosocially complex patients, enhancing patient engagement and self-management skills and reducing hospitalizations and emergency department visits.
A culturally tailored support group helps African-American women who are victims of intimate partner violence build coping skills, leading to reductions in depressive symptoms, levels of general distress, suicidal ideation, and suicide attempts.
A regional health commission made up of a diverse group of stakeholders promotes various activities and policies to support the safety-net health system, enhancing access to coverage, medical and dental care, and medical homes, and reducing readmissions and inappropriate use of the emergency department.
Supported by a central data repository, a statewide managed care plan for children and young adults in foster care provides ongoing care coordination, linkages to community-based services, and psychotropic drug utilization reviews, leading to better care access, better followup after mental illness hospitalization, and less use of psychotropic drugs.
A jointly governed consortium of more than 100 local organizations, the Milwaukee Enrollment Network helps county residents (particularly low-income and uninsured individuals) learn about and enroll in public and private health insurance plans.
Funded by and receiving referrals from the various public systems serving at-risk youth, Wraparound Milwaukee pays for and supports the provision of coordinated mental health and support services to children and adolescents with serious emotional and mental health needs, leading to less institutionalization and recidivism, lower costs, increased school attendance, better functioning at home and in school, and high satisfaction.
A group of 12 New Jersey hospitals offered upside incentives to individual physicians based on their performance on various efficiency metrics, leading to significant cost savings without negatively affecting quality of care.
Community health workers embedded in clinical teams in medical offices and hospitals support low-income patients in setting and achieving health-related goals and accessing needed medical and community-based services, leading to better communication and access to postdischarge primary care, increased patient activation, fewer readmissions and depression-related symptoms, and positive feedback from patients.
The Missouri Medicaid Health Home program provides capitated payments to primary care and mental health medical homes that adopt an integrated staffing model that allows patients to receive both medical and mental health care, leading to better health outcomes and lower utilization and costs.
A State-led accountable care collaborative provides comprehensive, coordinated care to Medicaid beneficiaries through primary care medical homes, reducing use of inpatient, imaging, and emergency department services, and generating estimated savings of $6 million for the State.