Care coordinator or case manager
A partnership between a hospital and retail pharmacy company provides inhospital and postdischarge support to patients at high risk of readmission, leading to fewer readmissions and high levels of patient satisfaction.
A recuperative care program provides homeless clients with housing, food, medical care, case management, and connections to social services after hospital discharge, resulting in improvements in their medical and housing status, fewer emergency department visits, and meaningful cost savings for participating hospitals.
A combined State-Federal program pays health plans a capitated fee to provide and coordinate acute, primary, long-term care as well as social services to those eligible for Medicare and Medicaid, leading to enhanced access to care, fewer inpatient admissions and nursing home placements, and high levels of beneficiary and provider satisfaction.
A collaborative initiative features standardized care elements and fixed per-patient payments for treatment of depression in the primary care setting, leading to high rates of remission and response to treatment and high levels of provider satisfaction.
A county-based accountable care organization integrates medical, behavioral health, and social services and assigns a care coordinator to newly enrolled Medicaid beneficiaries to promote use of appropriate services, leading to fewer readmissions and emergency department visits and lower costs.
A rural medical practice redesigned its care processes to allow multidisciplinary care teams to use a new electronic health record system that features real-time documentation and information sharing and various tools to facilitate the provision of appropriate care, leading to significant improvements in screening rates and high satisfaction for medically underserved patients in Alaska.
Nurse case managers at a Veterans Affairs hospital provide inhospital and post-discharge, telephone-based support to at-risk, community-dwelling patients and their caregivers, leading to better care transitions, fewer readmissions, and substantial cost savings.
A State-based, public–private partnership adapted its successful primary care medical home model to serve pregnant Medicaid beneficiaries, leading to enhanced access to comprehensive prenatal care (including intensive case management for high-risk pregnancies), better adherence to evidence-based care standards, and reductions in low–birth weight babies and rate of primary Cesarean sections.
Kaiser Permanente Colorado and the Visiting Nurse Association in Denver jointly offer intense, consistent education to elderly heart failure patients discharged from the hospital in need of home-based skilled nursing care, leading to improved knowledge and self-management skills and fewer readmissions.
Emergency department–based case managers at nine Milwaukee hospitals use electronic technologies to schedule and track attendance at follow-up clinic appointments for low-income, uninsured patients who come to the emergency department with nonurgent needs, allowing many such patients to establish a medical home.