Chronic care

Innovations

Solo Practitioner Uses Electronic Medical Record To Redesign Care Processes, Leading to Greater Adherence to Recommended Processes and Improved Outcomes 07/07/11

A solo practitioner leverages various functions within the electronic medical record to redesign care processes, leading to greater adherence to recommended care processes and improved outcomes for patients with diabetes.

Rheumatology Clinics Leverage Technology and Redesign Care Processes to Provide Physicians Relevant Patient Information, Improving Symptoms and Adherence to Recommended Care 07/06/11

Rheumatology clinics used information technology and redesigned associated care process to allow clinicians to access relevant patient information and focus scarce visit time on solving problems, leading to improvements in the provision of needed services and patient-reported symptoms.

Weekly Home Monitoring and Pharmacist Feedback Improve Blood Pressure Control in Hypertensive Patients 05/31/11

Hypertensive patients monitor and report multiple blood pressure readings each week and those with elevated readings receive pharmacist feedback and support, leading to better blood pressure control.

Case Management and Home Assessments Reduce Asthma-Related Admissions, Emergency Visits, and Missed School Days in Diverse Urban Children 05/29/11

Case management combined with in-home environmental assessment and remediation of environmental triggers reduce asthma-related hospitalizations, emergency department visits, missed school days, and missed parent work days in diverse, low-income urban children with asthma.

Affordable Housing Community Offers Seniors Onsite Health Care Coordination and Support, Reducing Hospital Admissions and Falls and Improving Resident Health 05/25/11

Onsite care coordination and support of seniors in affordable housing community leads to fewer falls, reduced hospital admissions, improved nutritional status, and increased levels of physical activity, promoting seniors' ability to remain in their homes as they age.

Registry Assists Physicians and School Nurses in Managing Childhood Asthma, Leading to Fewer Inpatient Admissions and Emergency Department Visits 05/24/11

A Web-based registry assists primary care physicians, pediatricians, and school nurses in managing childhood asthma, leading to significant reductions in inpatient admissions and emergency department visits.

Comprehensive, Culturally Sensitive Care and Self-Management Support Improves Health-Related Behaviors, Clinical Outcomes, and Emotional Health in Native Americans with Diabetes 05/06/11

The Full Circle Diabetes program provides comprehensive care and self-management support to Native Americans with diabetes, leading to improvements in health-related behaviors, clinical outcomes, and emotional health.

Community-Based Clinic Enhances Access to Medical Care and Reduces Emergency Department Visits for Chronically Ill Recently Released Prisoners 05/04/11

Community-based clinic enhances access to medical care and reduces emergency department visits for chronically ill individuals who have recently been released from prison.

American Indian Nation–Owned Skilled Nursing Facility Provides Culturally Responsive Services, Leading to High Patient Satisfaction and Low Staff Turnover 04/13/11

A Native American tribe–owned skilled nursing facility provides culturally competent services using a holistic approach to health and well-being, leading to high patient and family member satisfaction and low staff turnover.

Postdischarge Followup Calls to Skilled Nursing Facilities Reduce Heart Failure Readmissions by Two-Thirds 04/10/11

Hospital case managers telephone skilled nursing facility nurses within 48 hours of each heart failure patient's discharge to verify that appropriate care management is being provided, leading to a significant reduction in readmissions and associated cost savings.

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