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