Care coordinator or case manager
Community-based clinic enhances access to medical care and reduces emergency department visits for chronically ill individuals who have recently been released from prison.
Hospital case managers telephone skilled nursing facility nurses within 48 hours of each heart failure patient's discharge to verify that appropriate care management is being provided, leading to a significant reduction in readmissions and associated cost savings.
Volunteer physicians, supported by paid nurse case managers, provide homeless women with needed medical care in homeless shelters and connect the women to other needed medical and social services. The program has enhanced access to services, improved outcomes, and generated significant cost savings.
Medicaid managed care enrollees with type 2 diabetes receive free access to YMCA facilities and have regular meetings with nurses, dietitians, and personal trainers that focus on diet, exercise, and other aspects of disease self-management, leading to weight loss and improvements in body mass index, cholesterol, and blood glucose control.
A hospital links HIV-positive prisoners to medical care and other social services before and after release to enable successful reentry into the community, leading to enhanced access to these services and less recidivism.
A multidisciplinary, primary care center–based team used a culturally sensitive approach to screen, evaluate, and treat depressed Chinese Americans, leading to a sevenfold increase in treatment rates.
The Community Connections for Refugees with Disabilities program proactively identifies newly arriving refugees with disabilities, and then supports them in accessing culturally competent rehabilitation and community-based social services.
Culturally competent community liaisons help members of the Orthodox Jewish, Arab, and Chinese communities access health care and community-based services, leading to a better patient experience.
Emergency medical technicians screen rural-dwelling older adults for depression, medication-related problems, and falls. A case manager follows up with at-risk individuals to conduct an in-home assessment and provide needed referrals, leading to enhanced access to medical and social services and high levels of satisfaction.
Care coordinators remotely monitor veterans with chronic medical conditions via home telehealth devices, leading to reductions in hospital admissions, bed days, and care costs and to high levels of patient satisfaction.