A Medicare Advantage plan uses employed “extensivists” who perform traditional hospitalist functions for a smaller-than-average caseload of patients, and then continue to follow and care for these patients after discharge until their condition becomes stabilized, leading to low length of stay and fewer readmissions.
Pharmacists, pharmacy students or residents, and volunteers conduct clinics at primary care practices that help elderly, low-income patients access appropriate, cost-effective medications.
An interdisciplinary, hospital-based outpatient clinic staffed by geriatricians and other health professionals cares for seniors with one or more chronic health conditions, leading to improved outcomes and lower costs.
Commonwealth Care Alliance developed a health plan that provides low-income, dually eligible, elderly enrollees in Massachusetts with a primary care team made up of a physician, nurse practitioner, and geriatric specialist who work out of the enrollee's primary care clinic.
A community-based primary care clinic uses nurses to provide culturally competent care coordination to Latino patients with chronic illnesses and disabilities, leading to greater provision of recommended care, lower health care costs, and enhanced self-management capabilities.
Transitions coaches encourage recently hospitalized Medicare patients with complex care needs to assert a more active role in their posthospital care, leading to fewer readmissions and lower costs.
Dartmouth-Hitchcock Clinic assigned health coaches to high-risk chronic disease patients to provide instruction regarding health care needs over the phone, during office visits, and in group classes; the program reduced readmission rates and costs among elderly patients.
An interdisciplinary care management program that integrates medical and social care for low-income elderly patients with chronic illnesses reduces care costs and improves self-reported health status.