Frail elderly

Innovations

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.  

Trained Peers Educate and Support Veterans in Self-Management of Hypertension, Leading to Improved Blood Pressure and Weight Loss 09/17/14

Trained peers educate and support veterans in managing their blood pressure during regularly scheduled monthly meetings at Veterans Service Organization posts.

Community-Based Health Coaches and Care Coordinators Reduce Readmissions Using Information Technology To Identify and Support At-Risk Medicare Patients After Discharge 03/23/14

Supported by mobile technology, trained health coaches and nurse care coordinators use home visits and telephone-based monitoring to identify and address declines in health status in recently discharged Medicare patients, leading to a significant reduction in readmissions and associated cost savings.

Primary Care Physician Communication With Patients at or Soon After Discharge Significantly Reduces Medication Discrepancies 03/17/14

After being briefed by hospitalists, primary care physicians meet or talk by phone with patients who have complex medication regimens at or soon after discharge, leading to a significant reduction in medication discrepancies.

Long-Term Care Facilities Cede Control of Immunization Policies to Regional Pharmacy, Significantly Increasing Influenza Vaccination Rates Among Workers 01/30/14

A group of 14 long-term care facilities cede control of immunization policies to a regional pharmacy, leading to a significant increase in influenza vaccination rates among facility workers.

Community Health Workers Known as Promotores Enhance Access to Culturally Tailored Services for Elderly, Low-Income Racial/Ethnic Minorities, Leading to Improvements in Mental Health 12/05/13

Community health workers known as promotores enhance access to culturally competent mental health education and services, leading to improvements in mental health status and literacy for elderly racial and ethnic minorities.

State Uses Financial Incentives To Fund Nursing Home–Initiated Quality Improvement Projects Through Competitive Bidding Process, Leading to Better Care 11/07/13

The State of Minnesota uses financial rewards and penalties to fund nursing home–initiated quality improvement projects through a competitive bidding process, leading to improvements in the quality of care.

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.

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.

Community-Based, Culturally Tailored Diabetes Education Program Helps Low-Income South Korean Immigrants Improve Self-Management Behaviors, Disease Control, and Other Health Markers 06/10/13

A low-cost, community-based, culturally tailored education program led by a bilingual nurse practitioner helped Korean immigrants with type 2 diabetes improve self-management behaviors and achieve better control of the disease.

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