Avoidable hospitalizations

Innovations

Medical Center Establishes Infrastructure to Manage Care Under Capitated Contracts, Leading to Better Chronic Care Management and Lower Utilization and Costs 05/22/12

A university hospital established an infrastructure based on the principles of an accountable care organization, leading to improved management of chronic disease and reduced hospital admissions and medical expenses.

Insurer Provides Financial Incentives, Infrastructure, and Other Support To Stimulate Provider Participation in Quality Improvement Collaborations 05/21/12

A large insurer offers financial incentives and other support to provider-led quality improvement collaborations, leading to high levels of provider participation, higher quality, lower costs, and a positive return on investment.

Care Coordination, Peer Support, and Discretionary Fund Improve Quality of Life and Reduce Costs for Adults with Serious Mental Illness 01/14/12

Intensive, person-centered case management, peer support, and a discretionary fund for adults with serious mental illness leads to better access to treatment, job training, and employment; fewer suicide/self-harm attempts, hospitalizations, incarcerations, and days of homelessness; and lower mental illness-related costs.

Case Managers Remotely Monitor Chronically Ill Medicare Beneficiaries Each Day, Reducing Mortality and Costs 01/09/12

Case managers remotely monitor Medicare beneficiaries with chronic conditions via a messaging device that asks and records answers to disease-specific and general health questions each day, leading to lower mortality and costs.

System-Integrated Program Coordinates Care for People With Advanced Illness, Leading to Greater Use of Hospice Services, Lower Utilization and Costs, and High Satisfaction 12/20/11

The Advanced Illness Management program supports Medicare patients with advanced illness and their families in making patient-centered decisions, leading to greater use of hospice care, lower inpatient and ambulatory utilization and overall care costs, and high levels of patient, family, and physician satisfaction.

Church-Health System Partnership Facilitates Transitions From Hospital to Home for Urban, Low-Income African Americans, Reducing Mortality, Utilization, and Costs 11/29/11

A partnership between a large health system and 512 churches supports the transition from the hospital back into the community, leading to lower mortality, health care utilization, and health care costs and to higher satisfaction with hospital care.

Hospital-Based Social Workers Follow Up With Recently Discharged Older Adults to Resolve Transition Problems, Reducing Readmissions and Deaths 11/11/11

Hospital-based social workers support recently discharged older patients and their caregivers in resolving problems related to their transition back home, leading to enhanced patient and caregiver knowledge, better attendance at followup appointments, and fewer readmissions and deaths.

Trained Paramedics Provide Ongoing Support to Frequent 911 Callers, Reducing Use of Ambulance and Emergency Department Services 11/10/11

An emergency medical system provider uses advance practice paramedics to provide in-home and telephone-based support to patients who frequently call 911, reducing the use of ambulance and emergency department services.

Daily Nurse Review of Key Health Indicators Reduces Inpatient and Emergency Department Use for Patients on Dialysis 08/04/11

Nurses remotely monitor key indicators of end-stage renal disease patients and intervene as appropriate, leading to less inpatient and emergency department use and higher quality of life.

Patient Videos That Describe Care Experiences Spur Development of Many Successful Quality Improvement Initiatives 07/18/11

As part of Kaiser Permanente's Care Management Institute's video ethnography approach, provider teams interview patients about their care experiences, leading to the development of many quality improvement projects that have resulted in better care processes and outcomes.

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