Stage of Care
Certified peer specialists provide emotional support, education, links to community services, and other support to individuals with co-occurring medical and mental health diagnoses at two Michigan federally qualified health centers, generating high levels of satisfaction and anecdotal reports of improvements in physical and mental health.
Community health workers known as promotores enhance access to culturally competent mental health education and services, leading to improvements in mental health status and literacy for elderly racial and ethnic minorities.
A local foundation developed community-based testing programs and partnerships with medical homes to provide real-time linkages to HIV care to newly diagnosed patients and to support these patients in transitioning to care, nearly doubling the number of patients initiating treatment.
Emergency department and urgent care physicians and nurses use a protocol to help them decide how to treat patients complaining of pain who may be abusing controlled substances, leading to significantly fewer such patients receiving prescriptions for opioids.
A public–private urban health partnership develops multiple initiatives to expand access to high-quality, coordinated health care for vulnerable residents, leading to shorter wait times for appointments, improvements in patient–provider continuity, and reductions in readmissions and emergency department use.
The State of Minnesota uses financial rewards and penalties to fund nursing home–initiated quality improvement projects through a competitive bidding process, leading to improvements in the quality of care.
A primary care medical home for patients with disabilities and complex, chronic medical conditions emphasizes patient engagement and care coordination among medical specialties and social service providers, leading to enhanced access to care, better self-management skills, more days of good health, fewer hospitalizations, and lower costs.
A nonprofit, community-based organization matches uninsured and underinsured patients with physicians, hospitals, and other providers who agree to serve them at reduced fees and provides various sources of support to both providers and patients, leading to enhanced access to care and fewer emergency department visits.
Project BOOST (Better Outcomes by Optimizing Safe Transitions) provides hospitals a comprehensive set of interventions to improve the care transition process after discharge, leading to a significant reduction in readmissions.
Master's-level social workers operating out of a centralized department support primary care and specialty clinic patients in dealing with psychosocial and environmental issues, leading to high levels of patient/caregiver and practitioner satisfaction, improvements in patients' well-being and self-management skills, and reductions in resource use.