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 managing their blood pressure during regularly scheduled monthly meetings at Veterans Service Organization posts.
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.
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.
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 competent mental health education and services, leading to improvements in mental health status and literacy for elderly racial and ethnic minorities.
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.
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 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.
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.