A Medicare Advantage plan uses employed “extensivists” who perform traditional hospitalist functions for a smaller-than-average caseload of patients, and then continue to follow and care for these patients after discharge until their condition becomes stabilized, leading to low length of stay and fewer readmissions.
Ongoing case management, education, and peer support to low-income parents struggling with mental health and substance abuse disorders focuses on reducing the stigma associated with illness, increasing positive family interaction, and identifying and addressing cognitive and behavioral problems in children. Evidence suggests the program leads to less mental health–related stigma and stress, improved parenting skills and social support networks, few psychiatric hospitalizations, enhanced access to needed services for children, and many lasting family reunifications.
A tailored, home-based physical therapy program slows functional decline in moderately frail, community-dwelling older adults.
A senior center–based practitioner meets with functionally independent, community-dwelling seniors to assess risk factors and develop a targeted self-management plan, and conducts followup visits and telephone calls with the seniors over a 6-month period to help them adhere to the plan. The program has led to fewer disability days and risk factors for disability, improved self-reported health status and ability to perform activities of daily living, and reduced inpatient utilization.
Culturally competent parent mentors helped families better understand and care for their children's asthma through home visits, monthly telephone calls, and inperson meetings, leading to reductions in wheezing, exacerbations, missed school and parental work days, and emergency department visits.
Counseling and care coordination for patients with advanced illnesses improved patient–provider communication and the quality of medical care and decisionmaking support, leading to more patients completing advance directives and lower inpatient care requirements.
A medical center added outpatient palliative services, including symptom management and holistic emotional, psychosocial, and spiritual care, to its comprehensive inpatient palliative care services, leading to improved access and high levels of patient, family, and provider satisfaction.
A trained nurse educated other nurses, physicians, and administrators on evidence-based heart failure treatment and provided disease management education and followup support to high-risk patients, leading to fewer readmissions and lower costs.
Intensive case management and care coordination significantly reduces inpatient admissions and emergency department visits for costly, medically complex patients who lack insurance.
An intensive, nurse-led care management program provided during and after hospitalization reduced readmissions, inpatient days, and care costs for high-risk seniors.