Chronic care

Innovations

Periodic, Telephone-Based Assessment and Counseling Helps Stable Individuals With Alcohol or Cocaine Dependence Avoid Relapses 04/08/11

Experienced substance abuse counselors offer periodic, telephone-based assessment and counseling to individuals who have attained initial stability in alcohol and/or cocaine dependence, leading to comparable and in some cases better outcomes than traditional, more time-consuming face-to-face interventions.

Shelter-Based Medical Care and Case Management Enhance Access to Services for Homeless Women, Improve Outcomes, and Lower Costs 04/05/11

Volunteer physicians, supported by paid nurse case managers, provide homeless women with needed medical care in homeless shelters and connect the women to other needed medical and social services. The program has enhanced access to services, improved outcomes, and generated significant cost savings.

Medicaid Plan Offers Diabetic Patients Access to Fitness Facilities and Coaching, Leading to Weight Loss and Improvements in Cholesterol and Blood Glucose 03/21/11

Medicaid managed care enrollees with type 2 diabetes receive free access to YMCA facilities and have regular meetings with nurses, dietitians, and personal trainers that focus on diet, exercise, and other aspects of disease self-management, leading to weight loss and improvements in body mass index, cholesterol, and blood glucose control.

Specialists Train and Support Rural and Prison-Based Primary Care Clinicians, Enhancing Access to Hepatitis C Care 03/15/11

University-based specialists provide initial training and host weekly, case-based consultations with primary care clinicians, enhancing access to hepatitis C care for prisoners and rural patients throughout New Mexico.

Electronic and Telephone Reminders Increase Medication Adherence in Adults With Uncomplicated Hypertension 02/22/11

A specially designed pill-bottle system supplied visual and auditory reminders to patients, along with telephone reminders after missed doses and progress reports to be shared with providers; the program significantly increased medication adherence in those with uncomplicated hypertension.

Hospital Successfully Links Recently Released, HIV-Positive Prisoners to Medical, Mental Health, and Social Services, Reducing Recidivism 02/17/11

A hospital links HIV-positive prisoners to medical care and other social services before and after release to enable successful reentry into the community, leading to enhanced access to these services and less recidivism.

Day Hospital Reduces Inpatient Length of Stay and Emergency Department Visits for Patients With Sickle Cell Anemia 01/28/11

A Sickle Cell Day Hospital provides an alternative to inpatient care for patients with sickle cell anemia, with the goal of managing their pain and keeping them out of the hospital, resulting in lower inpatient lengths of stay and emergency department utilization.

Joint Nurse Practitioner–Geriatrician Management of Frail Elderly Increases Adherence to Recommended Care Processes for Common Conditions 01/27/11

Working in collaboration with geriatricians, a nurse practitioner comanaged the care of frail, elderly patients with any of five chronic conditions, leading to better adherence to recommended care processes.

Standardized Processes and Tools Significantly Enhance Provision of Recommended Care to Teens With Asthma 01/24/11

Teen Health Center providers use standardized processes and tools to enhance the provision of recommended care to teens with asthma.

Physician–Nurse House Calls Reduce Barriers to Health Care and Social Services for New Refugees 01/24/11

Physicians and nurses provide in-home routine medical care and assessments to newly arrived refugees, leading to enhanced access to health care and social services and better continuity of care for those with chronic illnesses.

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