Nurses remotely monitor key indicators of end-stage renal disease patients and intervene as appropriate, leading to less inpatient and emergency department use and higher quality of life.
A solo practitioner leverages various functions within the electronic medical record to redesign care processes, leading to greater adherence to recommended care processes and improved outcomes for patients with diabetes.
Using electronic templates, nurses and physicians provide a personalized report to patients at virtually every visit, with the goal of improving health-related behaviors; the program has contributed to a leveling off in the prevalence of overweight/obesity, above-average quit rates among smokers, better blood glucose control, and fewer racial disparities in chronic care.
The Full Circle Diabetes program provides comprehensive care and self-management support to Native Americans with diabetes, leading to improvements in health-related behaviors, clinical outcomes, and emotional health.
A primary care clinic offers patients 3- to 5-minute educational video modules, leading to enhanced patient knowledge without placing incremental demands on physicians and staff.
Primary care practices incorporate standing orders for preventive care services into the electronic health record, allowing nonphysician clinical staff to fill gaps in care; the program substantially increased the provision of needed services to eligible patients.
Through its commercial electronic medical record system, a large internal medicine practice provides physicians with unobtrusive reminders related to 16 standardized measures and makes it easy for them to order recommended tests or treatment or document legitimate exceptions, leading to better performance on these measures.
A free, online personal health record assists diabetes patients and their clinicians in monitoring key clinical indicators, communicating during and between office visits, and sharing information with other relevant individuals, leading to enhanced levels of patient engagement and improved blood glucose control.
Nurses and medical assistants use electronic tools and standardized workflows and processes before, during, and after the patient encounter to identify and address preventive, screening, and chronic care needs at every primary and specialty care visit, leading to greater adherence to recommended care processes and better blood pressure control in those with diabetes and hypertension.
Pharmacist coaches meet periodically with employees who have diabetes to assess health, monitor medications, and strengthen self-management skills, leading to better blood glucose and blood pressure control, greater adherence to recommended care processes, and lower overall health care costs.