A home health program enhances services to congestive heart failure and other chronically ill patients by supplementing at-home visits with ongoing remote monitoring and services.
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.
Baystate Medical Center's comprehensive heart failure management program incorporates tools and processes that ensure the provision of all necessary components of care, leading to increased adherence to recommended care and reduced heart failure readmission rates.
The Transition Home for Patients with Heart Failure program incorporates a number of components to ensure patients a safe transition to home or another health care setting, leading to fewer readmissions.
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.
A rural home health agency formalized oral and written communication processes with physicians, using specific communication tools to ensure that ongoing patient needs are being met; the program led to an increase in the use of home health services and a concomitant decline in inpatient admissions among home health patients.
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 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.
Cambridge Health Alliance enhanced its round-the-clock interpreter services by tracking key indicators that gauge the quality of these services; analyses of these data led to significant improvements in the program's telephone-based services and staff efficiency and the decision to implement depression screening in patients with limited English proficiency.
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).