Vulnerable populations

Innovations

Primary Care–Based, Multidisciplinary Teams Provide Care Management Services to Complex Patients, Enhancing Patient Engagement and Reducing Hospitalizations 06/27/16

Multidisciplinary teams embedded within primary care practices provide care management and other support services to medically and psychosocially complex patients, enhancing patient engagement and self-management skills and reducing hospitalizations and emergency department visits.

Community Paramedic Works Onsite in Homeless Shelter, Significantly Reducing Unnecessary 911 Calls and Connecting Residents to Primary Care 04/27/16

A community paramedic works onsite at a homeless shelter during afternoon and evening hours 4 days a week during periods when an onsite primary care clinic is not open, significantly reducing unnecessary 911 calls and connecting shelter residents to primary care.

Collaborative Health Education and Access Events Offer No-Cost Screenings and Navigation Services To Connect Lesbian, Gay, Bisexual, and Transgender Individuals With Medical Homes Offering Culturally Competent Care 12/19/14

Lesbian Health Initiative of Houston, Inc., creates a gateway to medical homes for lesbian, gay, bisexual, and transgender women and transgender men through a program that combines culturally competent outreach, education, screening, and patient navigation.

Specially Trained Paramedics Respond to Nonemergency 911 Calls and Proactively Care for Frequent Callers, Reducing Inappropriate Use of Emergency Services 12/19/14

Community Health Access Program helps patients who call 911with nonemergent needs. The dispatcher sends a specially trained paramedic, known as an advanced practice paramedic, to the scene along with the ambulance to confirm that the patient does not need emergency care and then either provide treatment, schedule an appointment with a primary care provider, or arrange for same-day transport to a health resource center.

Home Telemonitoring Does Not Improve Blood Pressure or Glycemic Control in Diabetes Patients 11/06/14

Home telemonitoring did not improve blood pressure or blood glucose control in diabetes patients with out-of-range values.

Electronic System for Referring Tobacco Users to Quitline and Monitoring Their Progress Increases Physician Referrals and Enhances Access to Cessation Services 11/05/14

An electronic system allows physicians at two health clinics to easily refer patients who use tobacco to a quitline and subsequently monitor their progress, leading to more clinician referrals to the quitline and enhanced access to cessation services for patients.

Health System–Community Partnership Expands Access to Insurance Coverage, Outpatient Care, Health Education, and Social Support in Low-Income, Minority Communities 11/05/14

A health system–community partnership offers resident-initiated programs that expand access to insurance coverage, outpatient care, health education, social support, healthy foods, and opportunities for physical activity for inner-city, low-income minorities.

Culturally Tailored Group Meetings and Other Support Help Abused African-American Women Build Coping Skills and Reduce Depressive Symptoms, Suicidal Thoughts, and Suicide Attempts 11/05/14

A culturally tailored support group helps African-American women who are victims of intimate partner violence build coping skills, leading to reductions in depressive symptoms, levels of general distress, suicidal ideation, and suicide attempts.

Awareness Campaign Targeting Young Minority Women Offers Free Home Test Kit for Sexually Transmitted Diseases, Increases Access to Screening and Treatment 11/04/14

A county health department's sexually transmitted disease awareness campaign targeting young minority women offers a free home test kit and improves access to testing and treatment, especially among African Americans and Latinas.

Physician-Led Clinics Offer Integrated, Coordinated Care to High-Risk Seniors Under Capitated Contracts, Leading to Strong Performance on Quality Metrics, Low Inpatient Use, and High Patient Satisfaction 11/04/14

A physician-led practice offers integrated, coordinated care under capitated contracts to high-risk, moderate- and low-income seniors enrolled in Medicare Advantage plans, leading to high levels of adherence to recommended screening services, good blood glucose control among patients with diabetes, below-average use of inpatient services, high patient satisfaction, and improvements in patient access to medications.  

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