Multidisciplinary teams embedded within primary care practices provide care management and other support services to medically and psychosocially complex patients, enhancing patient engagement and self-management skills and reducing hospitalizations and emergency department visits.
Community Health Access Program helps patients who call 911with nonemergent needs. The dispatcher sends a specially trained paramedic, known as an advanced practice paramedic, to the scene along with the ambulance to confirm that the patient does not need emergency care and then either provide treatment, schedule an appointment with a primary care provider, or arrange for same-day transport to a health resource center.
A physician-led practice offers integrated, coordinated care under capitated contracts to high-risk, moderate- and low-income seniors enrolled in Medicare Advantage plans, leading to high levels of adherence to recommended screening services, good blood glucose control among patients with diabetes, below-average use of inpatient services, high patient satisfaction, and improvements in patient access to medications.
A regional health commission made up of a diverse group of stakeholders promotes various activities and policies to support the safety-net health system, enhancing access to coverage, medical and dental care, and medical homes, and reducing readmissions and inappropriate use of the emergency department.
Children's National Health System has an emergency department–based clinic that serves low-income, minority children and teenagers with asthma.
Daily automated text messages combined with nurse followup improved self-management behaviors among patients with diabetes, leading to significant improvements in glycemic control, fewer doctor visits, lower costs, and high patient satisfaction.
Funded by and receiving referrals from the various public systems serving at-risk youth, Wraparound Milwaukee pays for and supports the provision of coordinated mental health and support services to children and adolescents with serious emotional and mental health needs, leading to less institutionalization and recidivism, lower costs, increased school attendance, better functioning at home and in school, and high satisfaction.
Supported by mobile technology, trained health coaches and nurse care coordinators use home visits and telephone-based monitoring to identify and address declines in health status in recently discharged Medicare patients, leading to a significant reduction in readmissions and associated cost savings.
After being briefed by hospitalists, primary care physicians meet or talk by phone with patients who have complex medication regimens at or soon after discharge, leading to a significant reduction in medication discrepancies.
Community health workers embedded in clinical teams in medical offices and hospitals support low-income patients in setting and achieving health-related goals and accessing needed medical and community-based services, leading to better communication and access to postdischarge primary care, increased patient activation, fewer readmissions and depression-related symptoms, and positive feedback from patients.