Care coordinator or case manager
A statewide program supports physician practices through multidisciplinary community-based health teams, preventive health expertise, easy access to needed information via electronic systems, and financial incentives, leading to lower utilization and growth in health care spending and enhanced provision of appropriate services.
Intensive, person-centered case management, peer support, and a discretionary fund for adults with serious mental illness leads to better access to treatment, job training, and employment; fewer suicide/self-harm attempts, hospitalizations, incarcerations, and days of homelessness; and lower mental illness-related costs.
Primary care physicians order standardized bundles of tests and specialty referrals for common diagnoses, which are then managed by a care coordination team, resulting in expedited patient care and high physician satisfaction.
Pharmacists provide ongoing chronic care management support to employees and their physicians, leading to greater adherence to recommended care processes and self-management behaviors, lower costs, higher productivity, and a significant return on investment.
Case managers remotely monitor Medicare beneficiaries with chronic conditions via a messaging device that asks and records answers to disease-specific and general health questions each day, leading to lower mortality and costs.
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.
Public health nurses provide case management services to women with one or more chronic conditions who receive Temporary Assistance for Needy Families, leading to enhanced access to mental health services, fewer depressive symptoms, and improved functional status.
Case management combined with in-home environmental assessment and remediation of environmental triggers reduce asthma-related hospitalizations, emergency department visits, missed school days, and missed parent work days in diverse, low-income urban children with asthma.
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.