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.
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.
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 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.
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.
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 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.
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.
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.
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.