Care coordinator or case manager
The Partners in Pregnancy program combines telephone-based case management with periodic home visits from registered nurses and community-based workers to improve pregnancy outcomes for high-risk pregnancies in a Medicaid managed care population.
A hospital-based outpatient disease management program serves patients with asthma, chronic heart failure, and diabetes and offers smoking cessation services to smokers. Unlike traditional disease management programs, this initiative heavily involves physicians in the initial referral and throughout the process and targets services toward the sickest patients (rather than to all patients with the condition).
A pediatric center provides comprehensive, coordinated services within a primary care medical home for low-income and immigrant children with special health care needs.
Faith community nurses provide case management, consultation, health education, screenings, and basic care at little or no cost to low-income, uninsured/underinsured individuals.
The Automated Telephone Diabetes Management program, a part of the IDEALL project, provided automated telephone monitoring of individuals with poorly controlled type II diabetes who receive their care at four safety net clinics in San Francisco.
An employer-based intervention to systematically screen workers for depression; provide telephonic outreach for needs assessment, monitoring, and support; and conduct telephonic psychotherapy demonstrated significantly improved clinical and workplace outcomes.
GreenField Health in Portland, OR, uses e-mail and telephone communications for the majority of patient contacts, thus saving physician time and freeing up capacity to serve patients who need inperson care more quickly.
Specially trained nurses work with primary care physicians in their offices to improve the quality and efficiency of care for seniors with multiple chronic illnesses by coordinating care, facilitating transitions in care, and acting as the patient's advocate across health care and social settings.
An interdisciplinary care management program that integrates medical and social care for low-income elderly patients with chronic illnesses reduces care costs and improves self-reported health status.
The Sutter Care Coordination Program combines chronic care and disease management to address the medical and psychosocial needs of individuals with multiple chronic conditions.