Care coordinators remotely monitor veterans with chronic medical conditions via home telehealth devices, leading to reductions in hospital admissions, bed days, and care costs and to high levels of patient satisfaction.
Rather than being placed on a specialized meal plan, diabetic inpatients order meals from an unrestricted (patient-controlled) menu after receiving education from nutrition staff about how to make appropriate food selections, with additional education provided to those consistently making “incorrect” choices. The program increased patient satisfaction without having a negative impact on the ability to achieve consistent carbohydrate intake and blood glucose control.
Supported by sophisticated information technology and a separate outreach team, cross-trained nurse practitioners run disease-specific clinics in which they educate patients about self-management and proactively manage and coordinate care related to diabetes, wounds, congestive heart failure, hypertension, pulmonary disease, and coronary artery disease; the program has led to significant improvements in outcomes across targeted diseases/conditions.
Guided by a health educator, medical assistants at an internal medicine practice are only modestly successful in encouraging diabetes patients to engage in goal setting, create personal action plans, and communicate home blood pressure and glucose measurements to physicians.
Financial incentives and associated support for employees and spouses to remain smoke-free, engage in physical activity, manage weight, achieve specific health-related milestones, and complete an annual physical exam and health risk appraisal lead to high participation rates and improvements in health-related behaviors and select health indicators.
Intensive case management and care coordination significantly reduces inpatient admissions and emergency department visits for costly, medically complex patients who lack insurance.
Interactive educational workshops enhance access to health screenings for low-income and minority women, leading to improved health outcomes for those with diabetes.
Reduced or waived drug copayments and pharmacist coaches cut costs and improve outcomes for employees with diabetes.
A church-sponsored, barbershop-based program enhances access to screening and treatment for hypertension, diabetes, and prostate and colon cancers for African-American men in Harlem.
Real-time clinical decision and documentation support through an electronic health record leads to more appropriate prescribing of antibiotics for respiratory infections and increased use of appropriate therapies and improved documentation for patients with diabetes and coronary artery disease.