Vulnerable populations

Innovations

Social Workers Support Outpatients in Dealing With Psychosocial Issues, Leading to High Patient and Practitioner Satisfaction and Better Patient Self-Management 10/21/13

Master's-level social workers operating out of a centralized department support primary care and specialty clinic patients in dealing with psychosocial and environmental issues, leading to high levels of patient/caregiver and practitioner satisfaction, improvements in patients' well-being and self-management skills, and reductions in resource use.

Statewide Partnership Provides Mental Health Assessments via Telemedicine to Patients in Rural Emergency Departments, Reducing Wait Times, Hospitalizations, and Costs 10/07/13

Through a statewide telemedicine program, psychiatrists evaluate patients with mental health issues who present at rural hospital emergency departments, leading to reductions in wait times, inpatient admissions, and costs; increased attendance at followup visits; and high levels of patient and clinician satisfaction.

Hospital Uses Data Analytics and Predictive Modeling To Identify and Allocate Scarce Resources to High-Risk Patients, Leading to Fewer Readmissions 08/13/13

A safety net hospital employs a software application that uses electronic health record data and predictive modeling to identify and allocate scarce resources to high-risk patients, leading to fewer readmissions and lower costs.

Legislatively Mandated, Permanent Council Serves as Effective Catalyst for Sustained Progress on End-of-Life Policy Issues in Maryland 08/12/13

A legislatively authorized, permanent council serves as an effective catalyst for concrete, sustained progress on high-priority policy issues related to end-of-life care in Maryland.

Urban Healthy Start Program Offers Support at Each Stage of Childbearing Cycle, Leading to Fewer Low- and Very Low–Birthweight Babies 08/09/13

A nonprofit organization in Baltimore provides programs and services to support at-risk women (particularly African Americans) throughout each stage of the childbearing cycle, leading to fewer deliveries of low- and very low–birthweight babies and associated cost savings.

Clinics Offer Culturally Tailored Diabetes Education and Culturally Appropriate Care to Ethiopian Patients, Leading to More Engagement, Better Outcomes, and Reduction of Health Disparities 07/29/13

A large health plan offered a 6-month program featuring culturally tailored educational classes and materials and the integration of culturally sensitive approaches into everyday care, leading to increased cultural sensitivity among staff, more engaged patients, and better health outcomes, and contributing (along with other programs) to the elimination of racial disparities.

Adding Diabetes and Hypertension Screening to Oral Health and Hygiene Program Identifies Many Seniors With or at Risk for These Chronic Illnesses 07/17/13

As an expansion to an existing community-based oral health program for Hispanic and African-American seniors, dental school faculty, staff, and students offer education and screening for hypertension and diabetes, leading to the identification of many seniors with or at high risk for these chronic illnesses and many previously diagnosed individuals who do not have the condition(s) under control.

Online System Speeds Enrollment in Medicaid and Children's Health Insurance Program, Significantly Reduces Operating Costs, and Contributes to Decline in Number of Uninsured 07/17/13

An online system provides real-time review and eligibility determination for applicants to Oklahoma's Medicaid and the Children's Health Insurance Program, leading to much quicker enrollment, significant cost savings, and a decline in the number of uninsured.

Care Coordinators Engage in Culturally Sensitive Discussions About Advance Directives With Seniors, Increasing Completion Rates and Reducing Disparities Between African Americans and Whites 07/11/13

Care coordinators in a large integrated system engage in culturally tailored discussions with low-income seniors about completing advance directives, leading to higher completion rates and a narrowing of the gap in completion rates between African Americans/black immigrants and whites.

Performance Feedback, Ultraviolet Cleaning Device, and Dedicated Housekeeping Team Significantly Improve Room Cleaning, Reduce Potential for Spread of Common, Dangerous Infection 06/24/13

A multifaceted program featuring education and feedback, ultraviolet room disinfection devices, and a dedicated housekeeping team significantly improved the thoroughness of room cleanings and reduced the percentage of rooms housing patients with Clostridium difficile infections that tested positive for the pathogen at patient discharge.

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