Community outreach workers identify residents at risk of nursing home placement and arrange for them to receive appropriate home- and community-based services, leading to fewer nursing home placements and significant cost savings.
Case managers remotely monitor Medicare beneficiaries with chronic conditions via a messaging device that asks and records answers to disease-specific and general health questions each day, leading to lower mortality and costs.
A nonprofit organization trains and places culturally competent home health workers to provide care for low-income, Asian-American seniors with limited English proficiency, leading to enhanced access to culturally competent care.
The Advanced Illness Management program supports Medicare patients with advanced illness and their families in making patient-centered decisions, leading to greater use of hospice care, lower inpatient and ambulatory utilization and overall care costs, and high levels of patient, family, and physician satisfaction.
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.
Onsite care coordination and support of seniors in affordable housing community leads to fewer falls, reduced hospital admissions, improved nutritional status, and increased levels of physical activity, promoting seniors' ability to remain in their homes as they age.
Volunteer physicians, supported by paid nurse case managers, provide homeless women with needed medical care in homeless shelters and connect the women to other needed medical and social services. The program has enhanced access to services, improved outcomes, and generated significant cost savings.
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.
A partnership between a health plan and psychiatric hospitals focuses on sharing of quarterly data, case reviews, and deployment of specific strategies to improve postdischarge care, leading to significant reductions in readmissions, inpatient days, and costs.
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.