Medical home

Innovations

Social Workers Support Outpatients in Dealing With Psychosocial Issues, Leading to High Patient and Practitioner Satisfaction and Better Patient Self-Management 10/21/13

Master's-level social workers operating out of a centralized department support primary care and specialty clinic patients in dealing with psychosocial and environmental issues, leading to high levels of patient/caregiver and practitioner satisfaction, improvements in patients' well-being and self-management skills, and reductions in resource use.

State Medicaid Program Adopts Multiple Policies to Significantly Increase Screening Rates and Enhance Access to Services for Young Children at Risk of Developmental Disabilities 06/10/13

The Oregon Health Authority (which oversees the State Medicaid program) initiated a series of policy changes to promote earlier detection, more effective referrals, and better coordination of care for pediatric patients with developmental delays, leading to a significant increase in screening rates and enhanced access to early intervention services.

Coordinated, Intensive Medical, Social, and Behavioral Health Services Improve Outcomes and Reduce Utilization for Frequent Emergency Department Users 03/04/13

Intensive, concurrent medical and behavioral health care, addiction services, and social service coordination improve patient outcomes and reduce health system use among patients who historically have been frequent users of emergency departments.

Plan-Supported Medical Home Model Helps Clinics Enhance Access, Improve Quality, and Reduce Admissions for Medicaid Managed Care Enrollees 03/03/13

A plan-supported medical home model used by clinics serving Medicaid managed care beneficiaries enhances access to care, improves quality, and reduces inpatient admissions.

Public-Private Partnership Supports Medical Homes in Managing Medicaid Enrollees via Disease/Case Management and Other Initiatives, Leading to Higher Quality and Significant Cost Savings 02/22/13

A state-based, public–private partnership supports medical homes in managing the care of Medicaid managed-care enrollees, leading to higher quality and significant reductions in utilization and costs.

County-Based Accountable Care Organization for Medicaid Enrollees Features Shared Risk, Electronic Data Sharing, and Various Improvement Initiatives, Leading to Lower Utilization and Costs 02/14/13

A county-based accountable care organization integrates medical, behavioral health, and social services and assigns a care coordinator to newly enrolled Medicaid beneficiaries to promote use of appropriate services, leading to fewer readmissions and emergency department visits and lower costs.

Community Partners Offer Financial Incentives and Support for Primary Care Practices, Improving Access and Reducing Utilization for Children on Medicaid 02/06/13

The Children's Healthcare Access Program offers financial incentives and support services to primary care medical homes serving children covered by Medicaid and their families; the program enhanced access to primary care, increased the percentage of children with asthma action plans, reduced emergency department visits and hospital admissions, increased well-child visits, and reduced costs.

Statewide Medical Home Program for Low-Income Pregnant Women Enhances Access to Comprehensive Prenatal Care and Case Management, Improves Outcomes 12/06/12

A State-based, public–private partnership adapted its successful primary care medical home model to serve pregnant Medicaid beneficiaries, leading to enhanced access to comprehensive prenatal care (including intensive case management for high-risk pregnancies), better adherence to evidence-based care standards, and reductions in low–birth weight babies and rate of primary Cesarean sections.

Teams of Diabetes Educators Regularly Visit Rural Clinics to Coach African-American Patients, Leading to Better Glycemic Control and Potential Cost Savings 11/19/12

A traveling team of certified diabetes educators (including a nurse, pharmacist, and dietitian) regularly visits rural clinics to help coordinate diabetes care with clinicians and educate and coach African-American patients with diabetes, leading to improved glycemic control and the potential for meaningful cost savings.

Community-Based Oncology Practice Redesigns Processes Based on Patient-Centered Medical Home Model To Enhance Access, Improve Quality, and Reduce Costs 11/12/12

A community-based oncology practice's patient-centered medical home model features oncology-specific information technology, a standardized assessment, multidisciplinary care plan, patient navigators, telephone triage line, patient education and engagement, and ongoing performance monitoring, leading to improvements in access, quality, and costs.

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