A partnership between a large health system and 512 churches supports the transition from the hospital back into the community, leading to lower mortality, health care utilization, and health care costs and to higher satisfaction with hospital care.
Small-group discussions and automated, interactive phone calls over a 12-week period helped low-income parents promote healthier behaviors in their overweight children, leading to reductions in body mass index and improvements in health-related quality of life.
Hospital-based social workers support recently discharged older patients and their caregivers in resolving problems related to their transition back home, leading to enhanced patient and caregiver knowledge, better attendance at followup appointments, and fewer readmissions and deaths.
Through a partnership between the Veterans Administration and the Alzheimer's Association, a two-person care coordinator team provided support to patients with dementia and their caregivers over a 12-month period. The program led to improved psychosocial outcomes for veterans and caregivers, fewer readmissions and institutional placements, enhanced access to outpatient services, and higher overall health care costs.
An emergency medical system provider uses advance practice paramedics to provide in-home and telephone-based support to patients who frequently call 911, reducing the use of ambulance and emergency department services.
A partnership between academic medicine and a major-league sports team enhances access to care by providing treatment and support to veterans who suffer from traumatic brain injury and posttraumatic stress disorder and their families, generating high levels of patient satisfaction.
A culturally tailored smoking cessation program significantly reduces tobacco use among members of an American Indian tribe.
Individual and group support enhances the skills and knowledge of those caring for patients with dementia, leading to less caregiver burden and depression and fewer problem behaviors among patients.
Onsite care coordination and support of seniors in affordable housing community leads to fewer falls, reduced hospital admissions, improved nutritional status, and increased levels of physical activity, promoting seniors' ability to remain in their homes as they age.
The Full Circle Diabetes program provides comprehensive care and self-management support to Native Americans with diabetes, leading to improvements in health-related behaviors, clinical outcomes, and emotional health.