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 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.
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 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.
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.
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.
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 individuals who have recently been released from prison.
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.
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.