Medicare

Innovations

Outreach Workers Connect Low-Income Individuals Living in Rural Areas to Home- and Community-Based Services, Reducing Costs and Nursing Home Placements 02/01/12

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 Chronically Ill Medicare Beneficiaries Each Day, Reducing Mortality and Costs 01/09/12

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.

Agency Enhances Access to Culturally Competent Home Care by Providing Trained Aides to Asian American Seniors With Limited English Proficiency 12/27/11

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.

System-Integrated Program Coordinates Care for People With Advanced Illness, Leading to Greater Use of Hospice Services, Lower Utilization and Costs, and High Satisfaction 12/20/11

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.

Multispecialty Practice Uses Electronic Templates to Provide Customized Support at Every Visit, Contributing to Improved Patient Behaviors and Outcomes 06/03/11

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.

Affordable Housing Community Offers Seniors Onsite Health Care Coordination and Support, Reducing Hospital Admissions and Falls and Improving Resident Health 05/25/11

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.

Shelter-Based Medical Care and Case Management Enhance Access to Services for Homeless Women, Improve Outcomes, and Lower Costs 04/05/11

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.

In-Office Education via Hand-Held Electronic Device Enhances Patient Knowledge Without Burdening Primary Care Staff 03/22/11

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.

Health Plan and Psychiatric Hospitals Reduce Readmissions by Reviewing Data and Developing Strategies to Improve Postdischarge Care 01/13/11

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.

Health Plan Uses Nurse Practitioners to Improve Outcomes for Seniors With Diabetes, Congestive Heart Failure, Hypertension, and Wounds 07/13/10

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.

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