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