Teen Health Center providers use standardized processes and tools to enhance the provision of recommended care to teens with asthma.
A partnership between a health plan and psychiatric hospitals focuses on sharing of quarterly data, case reviews, and deployment of specific strategies to improve postdischarge care, leading to significant reductions in readmissions, inpatient days, and costs.
A transitional care program that identifies frail elderly patients in the hospital and provides them with in-home support after discharge significantly reduces readmissions and emergency department visits.
A dementia care facility takes a person-centered approach to caring for residents who exhibit challenging, aggressive behavior, leading to less need for psychiatric hospitalizations and behavior-related medications.
Health coaches work with at-risk individuals over the phone to develop skills and plans to participate effectively in shared clinical decisionmaking with physicians, self-manage their conditions, and navigate the health system, leading to reduced hospital admissions and medical costs when offered to a larger portion of the population.
Care coordinators remotely monitor veterans with chronic medical conditions via home telehealth devices, leading to reductions in hospital admissions, bed days, and care costs and to high levels of patient satisfaction.
Health system pharmacists telephone recently discharged patients to complete medication reconciliation and provide medication-related education, leading to significant reductions in readmission rates and high levels of patient satisfaction.
The seven-county New York Care Coordination Program offers comprehensive care coordination for individuals with severe mental illness through assessment, individualized goal setting, and access to social programs, leading to improved quality of life and coping skills, fewer emergency department visits and inpatient days, and lower costs.
Supported by sophisticated information technology and a separate outreach team, cross-trained nurse practitioners run disease-specific clinics in which they educate patients about self-management and proactively manage and coordinate care related to diabetes, wounds, congestive heart failure, hypertension, pulmonary disease, and coronary artery disease; the program has led to significant improvements in outcomes across targeted diseases/conditions.
Health navigators help primary care patients access medical and community resources, leading to significant improvements in health-related and self-management behaviors and health outcomes and to meaningful declines in emergency department and inpatient utilization.