Care coordinator or case manager

Innovations

Telephone-Based Case Management and Periodic Home Visits Reduce Neonatal Intensive Care Unit Utilization and Overall Costs for High-Risk Pregnant Women and Their Babies 03/14/08

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.

Disease Management Programs Improve Adherence to Evidence-Based Processes and Outcomes by Targeting Sickest Patients and Working Closely With Physicians 03/14/08

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).

Pediatric Center Offers Coordinated, Culturally Appropriate Services, Increasing Access to Comprehensive Care for Low-Income Children With Special Health Care Needs 03/07/08

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 Work With Local, Trusted Organizations to Enhance Access to Primary and Preventive Care for Low-Income Individuals in Los Angeles 02/25/08

Faith community nurses provide case management, consultation, health education, screenings, and basic care at little or no cost to low-income, uninsured/underinsured individuals.

Automated, Telephone-Based Interactive, Language-Appropriate Monitoring Engages and Improves Health Behaviors of Low-Income Diabetes Patients 02/22/08

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.

Employer-Based Telephone Screening, Outreach, and Care Management for Depressed Workers Improves Clinical and Workplace Outcomes 01/31/08

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.

E-Mail and Telephone Contact Replaces Most Patient Visits in Primary Care Practice, Leads to More Engaged Patients and Time Savings for Physicians 01/28/08

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.

Onsite Nurses Manage Care Across Settings to Increase Satisfaction and Reduce Cost for Chronically Ill Seniors 01/21/08

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.

Postdischarge Care Management Integrates Medical and Psychosocial Care of Low-Income Elderly Patients 01/16/08

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.

Chronic Care and Disease Management Improves Health, Reduces Costs for Patients With Multiple Chronic Conditions in an Integrated Health System 12/20/07

The Sutter Care Coordination Program combines chronic care and disease management to address the medical and psychosocial needs of individuals with multiple chronic conditions.

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