Care coordinator or case manager

Innovations

Community- and Practice-Based Teams, Real-Time Information, and Financial Incentives Help Medical Homes Improve Care, Reduce Utilization and Costs 09/29/09

As part of a statewide, public-private initiative, a largely rural Vermont community supports its six medical patient-centered medical home practices with a multidisciplinary provider team, real-time electronic information, and insurer-funded financial incentives, leading to more appropriate care and services and lower utilization and growth in health care spending.

Medicaid Plan-Sponsored Support of Case Managers Serving High-Cost Enrollees With Substance Abuse Disorders Enhances Access to Services Without Increasing Costs 08/06/09

Ongoing support to nurse case managers improves their ability to serve high-cost Medicaid managed care enrollees with co-occurring medical conditions and substance abuse problems, enhancing access to services and treatment without significantly raising costs.

Daily Remote Monitoring and As-Needed Nurse Contacts Reduce Unexpected Clinic Visits, Hospitalizations for Chemotherapy Patients 01/28/09

Daily, telehealth-enabled symptom monitoring combined with as-needed interactions with a nurse reduced unexpected clinic visits and inpatient use among cancer patients undergoing chemotherapy.

Postdischarge Telephone Followup With Chronic Disease Patients Reduces Hospitalizations, Emergency Department Visits, and Costs 09/11/08

A chronic care coordination program employs coordinators to provide telephone-based support to recently discharged patients and other high-risk enrollees, leading to fewer hospitalizations and emergency department visits and lower costs.

Plan-Funded Team Coordinates Enhanced Primary Care and Support Services to At-Risk Seniors, Reducing Hospitalizations and Emergency Department Visits 08/08/08

Commonwealth Care Alliance developed a health plan that provides low-income, dually eligible, elderly enrollees in Massachusetts with a primary care team made up of a physician, nurse practitioner, and geriatric specialist who work out of the enrollee's primary care clinic.

School-Based Transition Program Connecting High-Risk Adolescents to Mental Health and Support Services Improves Academic and Familial Functioning 07/29/08

The Brookline Resilient Youth Team assists teenagers and their families who have recently experienced serious emotional disorders, medical issues, substance abuse, and/or other problems.

Cooperative Network Improves Patient Transitions Between Hospitals and Skilled Nursing Facilities, Reducing Readmissions and Length of Hospital Stays 07/04/08

Summa Health System's Care Coordination Network strives to ensure smooth transitions between the hospitals and 40 local skilled nursing facilities, leading to fewer readmissions and lower length of stay in the hospital.

Team-Developed Care Plan and Ongoing Care Management by Social Workers and Nurse Practitioners Result in Better Outcomes and Fewer Emergency Department Visits for Low-Income Seniors 04/25/08

As part of the Geriatric Resources for Assessment and Care of Elders (GRACE) program, social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for low-income seniors, leading to significant improvements in health status.

Health Plan–Financed, Nurse-Led Care Coordination Improves Quality of Care and Reduces Costs for Latinos With Chronic Illnesses and Disabilities 04/21/08

A community-based primary care clinic uses nurses to provide culturally competent care coordination to Latino patients with chronic illnesses and disabilities, leading to greater provision of recommended care, lower health care costs, and enhanced self-management capabilities.

Integrating Behavioral Health and Nutrition Services Into Primary Care Clinics Significantly Reduces Mental Health-Related Hospitalizations for Staff-Model Health Maintenance Organization 03/28/08

A health maintenance organization integrated mental and behavioral health care and nutrition services with primary care delivery, leading to a more than 50-percent reduction in mental health–related hospitalizations.

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