Stage of Care
To improve emergency department patient satisfaction and throughput, St. Francis Medical Center in Los Angeles implemented a comprehensive bundle of interrelated strategies.
La Cheim Behavioral Health Services began offering a series of posthospitalization meetings and support services for “alumni” who had achieved their therapeutic goals in partial hospitalization or intensive outpatient therapy.
Specially trained nurses work with primary care physicians in their offices to improve the quality and efficiency of care for seniors with multiple chronic illnesses by coordinating care, facilitating transitions in care, and acting as the patient's advocate across health care and social settings.
A nurse-led program did not improve adherence to antiretroviral medications for patients with human immunodeficiency virus who are either homeless or live in marginal housing.
Reid Hospital created a computer-based system of alerts, standing orders, and care pathways to eliminate gaps in the care of patients with pneumonia, acute myocardial infarction, and heart failure, and to address surgical complication and infection prevention, leading to significant improvements in quality of care.
Dartmouth-Hitchcock Clinic assigned health coaches to high-risk chronic disease patients to provide instruction regarding health care needs over the phone, during office visits, and in group classes; the program reduced readmission rates and costs among elderly patients.
Mayo Clinic's staff shadowed physicians and worked closely with them to improve the clinic's information system to better support providers and enhance the patient care process in inpatient and outpatient settings.
The University of Washington Physician's Network developed a wireless, pager-based messaging system to help diabetic patients better manage their condition. An evaluation of the initiative found that it had no impact on blood glucose levels, although blood pressure improved.
An interdisciplinary care management program that integrates medical and social care for low-income elderly patients with chronic illnesses reduces care costs and improves self-reported health status.
A partnership between a hospice organization and an 11-location multispecialty group practice places palliative care nurses in primary care clinics to monitor dying patients' medical and social care needs, coordinate community services, and discuss end-of-life issues.