A health system–community partnership offers resident-initiated programs that expand access to insurance coverage, outpatient care, health education, social support, healthy foods, and opportunities for physical activity for inner-city, low-income minorities.
The MyRx Medication Adherence Program offers culturally and linguistically tailored medication management and health education to seniors with hypertension or diabetes who were living in the community.
This culturally tailored program educates minority populations with diabetes, hypertension, or overweight/obesity about appropriate management of these conditions.
Daily automated text messages combined with nurse followup improved self-management behaviors among patients with diabetes, leading to significant improvements in glycemic control, fewer doctor visits, lower costs, and high patient satisfaction.
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 State of Maryland provides financial and technical support to five communities designated through a competitive bidding process as health enterprise zones, leading to an expansion of primary care capacity in these areas.
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.
Community health workers provided culturally tailored workshops and one-on-one counseling and support to Filipino Americans at high risk of cardiovascular disease, leading to greater adherence to medication regimens, better attendance at scheduled appointments, improved blood pressure control, and lower body mass index.
A safety net hospital employs a software application that uses electronic health record data and predictive modeling to identify and allocate scarce resources to high-risk patients, leading to fewer readmissions and lower costs.
A large health plan offered a 6-month program featuring culturally tailored educational classes and materials and the integration of culturally sensitive approaches into everyday care, leading to increased cultural sensitivity among staff, more engaged patients, and better health outcomes, and contributing (along with other programs) to the elimination of racial disparities.