A mental and behavioral health team periodically works onsite at health plan centers to facilitate patient access to mental health services, reducing psychiatric inpatient utilization and generating high levels of staff satisfaction.
Intensivists guide care around the clock in two medical–surgical intensive care units, leading to lower length of stay and the near elimination of ventilator-associated pneumonia, hospital-acquired pressure ulcers, and central line infections.
Asthma educators help patients, providers, school nurses, childcare providers, pharmacists, and others in the community achieve optimal asthma treatment, leading to fewer hospitalizations, emergency department visits, and missed work days.
Daily, telehealth-enabled symptom monitoring combined with as-needed interactions with a nurse reduced unexpected clinic visits and inpatient use among cancer patients undergoing chemotherapy.
A nurse practitioner–led service to bridge the gap in care for recently discharged patients awaiting a followup appointment did not reduce the rate of unplanned readmissions.
A hospital uses a protocol to encourage ambulation in hospitalized patients with community-acquired pneumonia and chronic obstructive pulmonary disease, leading to a reduction in readmissions and length of stay.
The Urban Health Plan Asthma Relief Street program provides standardized, comprehensive asthma screening, guideline-based treatment, education, and self-management support, leading to more people being diagnosed and treated, fewer hospitalizations, and overall cost savings.
A home-based model of palliative care uses an interdisciplinary team of providers to manage symptoms and pain, provide emotional and spiritual support, and educate patients and family members about changes in the patient's condition.
A comprehensive asthma management program that includes a registry of all asthma patients, action plans, home visits from nurses, and specialized services for high-risk children led to a reduction in asthma-related hospitalizations and pediatric emergency department visits.
A chronic care coordination program employs coordinators to provide telephone-based support to recently discharged patients and other high-risk enrollees, leading to fewer hospitalizations and emergency department visits and lower costs.