Medically or socially complex
Multidisciplinary teams embedded within primary care practices provide care management and other support services to medically and psychosocially complex patients, enhancing patient engagement and self-management skills and reducing hospitalizations and emergency department visits.
Community Health Access Program helps patients who call 911with nonemergent needs. The dispatcher sends a specially trained paramedic, known as an advanced practice paramedic, to the scene along with the ambulance to confirm that the patient does not need emergency care and then either provide treatment, schedule an appointment with a primary care provider, or arrange for same-day transport to a health resource center.
Home telemonitoring did not improve blood pressure or blood glucose control in diabetes patients with out-of-range values.
A physician-led practice offers integrated, coordinated care under capitated contracts to high-risk, moderate- and low-income seniors enrolled in Medicare Advantage plans, leading to high levels of adherence to recommended screening services, good blood glucose control among patients with diabetes, below-average use of inpatient services, high patient satisfaction, and improvements in patient access to medications.
Primary care clinics integrate a full-time behavioral health team and part-time consulting psychiatrist into the practice, enhancing access to behavioral health services, helping patients become more engaged in their own care, and increasing primary care clinician involvement in addressing patients' behavioral health issues.
Supported by a central data repository, a statewide managed care plan for children and young adults in foster care provides ongoing care coordination, linkages to community-based services, and psychotropic drug utilization reviews, leading to better care access, better followup after mental illness hospitalization, and less use of psychotropic drugs.
The MyRx Medication Adherence Program offers culturally and linguistically tailored medication management and health education to seniors with hypertension or diabetes who were living in the community.
Supported by mobile technology, trained health coaches and nurse care coordinators use home visits and telephone-based monitoring to identify and address declines in health status in recently discharged Medicare patients, leading to a significant reduction in readmissions and associated cost savings.
After being briefed by hospitalists, primary care physicians meet or talk by phone with patients who have complex medication regimens at or soon after discharge, leading to a significant reduction in medication discrepancies.
The Missouri Medicaid Health Home program provides capitated payments to primary care and mental health medical homes that adopt an integrated staffing model that allows patients to receive both medical and mental health care, leading to better health outcomes and lower utilization and costs.