Care coordinator or case manager
A joint case management program sponsored by two competing hospitals addresses the health and social needs of uninsured and underinsured individuals who have a history of using the emergency department for nonemergent issues. The program has led to enhanced access to appropriate care and to a significant decline in emergency department use and costs for nonemergent conditions.
School-based, culturally appropriate therapy focused on dealing with trauma helps West African refugee children improve coping skills and academic performance.
A combination of telephone-based nurse case management and automated symptom monitoring leads to significant reductions in the severity of pain and depression in cancer patients being treated in urban and rural oncology practices.
The seven-county New York Care Coordination Program offers comprehensive care coordination for individuals with severe mental illness through assessment, individualized goal setting, and access to social programs, leading to improved quality of life and coping skills, fewer emergency department visits and inpatient days, and lower costs.
Health navigators help primary care patients access medical and community resources, leading to significant improvements in health-related and self-management behaviors and health outcomes and to meaningful declines in emergency department and inpatient utilization.
Ongoing case management, education, and peer support to low-income parents struggling with mental health and substance abuse disorders focuses on reducing the stigma associated with illness, increasing positive family interaction, and identifying and addressing cognitive and behavioral problems in children. Evidence suggests the program leads to less mental health–related stigma and stress, improved parenting skills and social support networks, few psychiatric hospitalizations, enhanced access to needed services for children, and many lasting family reunifications.
Care staff use software-based protocols to screen older clients' medications and collaborate with pharmacists and physicians to reduce the risk of medication errors and adverse effects, leading to more appropriate medication use and fewer cases of duplicative medications.
A capitated system proactively identifies, screens, and treats those with or at risk for osteoporosis, leading to a 49 percent decline in hip fractures, more than 350 lives saved each year, and tens of millions of dollars in annual cost savings.
Care managers working with low-income patients with severe mental illness in a community mental health clinic enhanced access to recommended preventive, primary, and specialty medical services, leading to the diagnosis of previously undetected conditions and improved physical and mental health.
Intensive case management and care coordination significantly reduces inpatient admissions and emergency department visits for costly, medically complex patients who lack insurance.