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.
A group of 14 long-term care facilities cede control of immunization policies to a regional pharmacy, leading to a significant increase in influenza vaccination rates among facility workers.
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 combined State-Federal program pays health plans a capitated fee to provide and coordinate acute, primary, long-term care as well as social services to those eligible for Medicare and Medicaid, leading to enhanced access to care, fewer inpatient admissions and nursing home placements, and high levels of beneficiary and provider satisfaction.
A program known as Cash & Counseling gives Medicaid enrollees a monthly allowance for home care and related services that they can spend at their own discretion, leading to enhanced access to services, fewer unmet needs, improved health outcomes, and high levels of beneficiary satisfaction.
Nurse case managers at a Veterans Affairs hospital provide inhospital and post-discharge, telephone-based support to at-risk, community-dwelling patients and their caregivers, leading to better care transitions, fewer readmissions, and substantial cost savings.
The California Department of Health provides education and support to hospitals throughout the state, allowing many to create programs to address appropriate use of antimicrobials in response to State legislation.
Community outreach workers identify residents at risk of nursing home placement and arrange for them to receive appropriate home- and community-based services, leading to fewer nursing home placements and significant cost savings.
A nonprofit organization trains and places culturally competent home health workers to provide care for low-income, Asian-American seniors with limited English proficiency, leading to enhanced access to culturally competent care.
Individual and group support enhances the skills and knowledge of those caring for patients with dementia, leading to less caregiver burden and depression and fewer problem behaviors among patients.