Vulnerable populations

Resident-Assisted Montessori Programming (RAMP) is a peer leadership program in which patients in the early stages of dementia are trained to lead group activities with their peers who have more advanced dementia. Using principles of the Montessori learning method, RAMP teaches early-stage patients to use their strengths, such as procedural memory, to engage patients in meaningful social roles.

The Sutter Care Coordination Program combines chronic care and disease management to address the medical and psychosocial needs of individuals with multiple chronic conditions.

CarePartners, a donated care program, matches uninsured Maine residents with primary care physicians who are willing to care for up to 10 patients for free. Case managers help enrollees obtain needed services, including hospital care, specialist services, and free or low-cost drugs through prescription assistance programs.

Remote diabetic retinopathy screening using the Eye Picture Archive Communication System digital ocular imaging software facilitated prompt retinopathy diagnosis in California's Central Valley, an area where many residents are poor and uninsured and diabetes is a major health concern.

Mayo Clinic therapists conduct remote cognitive rehabilitation sessions with acquired brain injury patients who remain in or near their homes, thus enhancing access to care for those who find it difficult to travel for face-to-face sessions.

The Migrant Clinicians Network Prenatal Care Program seeks to ensure continuity of care for expectant mothers who begin prenatal care in one location and move for employment purposes during their pregnancy. Bilingual, culturally competent staff link migrant patients with prenatal services and manage their medical records throughout the pregnancy.

Essentia Health Heart and Vascular Center created a heart failure program combining chronic care and disease management principles to improve outcomes and reduce costs associated with heart failure care.

Planned Parenthood of the Columbia/Willamette created an online service that offers Oregon and Washington women easy, 24/7 access to low-dose, hormonal contraception without requiring an office visit or a trip to the drug store.

Fairview Health Services' palliative care program offers palliative care clinical and support services to inpatients, outpatients, and home care patients to mitigate suffering and improve quality of life; the program is integrated into the care process to facilitate referrals and care coordination.

The Care Management Plus program combines the care coordination services of a care manager with robust electronic tracking and reminder systems to deliver comprehensive medical care to seniors with multiple chronic illnesses in primary care clinics.