Chronic care

Innovations

Proactive Office Encounter Systematically Identifies and Addresses Preventive and Chronic Care Needs at Every Primary Care and Specialty Visit 11/30/10

Nurses and medical assistants use electronic tools and standardized workflows and processes before, during, and after the patient encounter to identify and address preventive, screening, and chronic care needs at every primary and specialty care visit, leading to greater adherence to recommended care processes and better blood pressure control in those with diabetes and hypertension.

Transitional Care Program With Advance Care Planning for Frail Elders Reduces Emergency Department Visits and Readmissions 11/29/10

A transitional care program that identifies frail elderly patients in the hospital and provides them with in-home support after discharge significantly reduces readmissions and emergency department visits.

Telephone Consultations Improve Medication Adherence and Physical Functioning in Patients With Rheumatoid Arthritis 11/02/10

A licensed pharmacist or registered nurse periodically consults via telephone over a 7-month period with adult patients with rheumatoid arthritis, leading to improvements in medication adherence and physical functioning and to high levels of patient satisfaction.

Pharmacist Coaching and Waived Copayments Lead to Better Outcomes and Lower Costs for Employees With Diabetes 11/02/10

Pharmacist coaches meet periodically with employees who have diabetes to assess health, monitor medications, and strengthen self-management skills, leading to better blood glucose and blood pressure control, greater adherence to recommended care processes, and lower overall health care costs.

Telephone-Based Coaching on Shared Decisionmaking, Behavioral Change, and Health System Navigation Reduces Utilization and Cost 10/27/10

Health coaches work with at-risk individuals over the phone to develop skills and plans to participate effectively in shared clinical decisionmaking with physicians, self-manage their conditions, and navigate the health system, leading to reduced hospital admissions and medical costs when offered to a larger portion of the population.

Care Coordinators Remotely Monitor Chronically Ill Veterans via Messaging Device, Leading to Lower Inpatient Utilization and Costs 10/25/10

Care coordinators remotely monitor veterans with chronic medical conditions via home telehealth devices, leading to reductions in hospital admissions, bed days, and care costs and to high levels of patient satisfaction.

Hospital Partnership Offers Pathways-Based Case Management Program, Leading to Enhanced Access to Appropriate Care for Uninsured 10/19/10

A joint case management program sponsored by two competing hospitals addresses the health and social needs of uninsured and underinsured individuals who have a history of using the emergency department for nonemergent issues. The program has led to enhanced access to appropriate care and to a significant decline in emergency department use and costs for nonemergent conditions.

Weekly Parent and Child Sessions Focused on Mealtime Behaviors Increase Caloric Intake and Weight Gain in Children With Cystic Fibrosis 10/11/10

Behavioral health clinicians led weekly sessions for parents and children that combined nutrition education with the teaching of practical strategies for managing the eating-related behaviors of children with cystic fibrosis, resulting in increases in caloric intake and weight in these children.

Telephone-Based Care Management With Automated Symptom Monitoring Reduces Pain and Depression in Cancer Patients 09/14/10

A combination of telephone-based nurse case management and automated symptom monitoring leads to significant reductions in the severity of pain and depression in cancer patients being treated in urban and rural oncology practices.

Integrated Behavioral Health Reduces Depression and Anxiety in Primary Care Patients, Improving Quality of Life and Reducing Costs 08/26/10

A primary care clinic integrates behavioral health assessment and treatment into the care of its largely low-income population, leading to better access to mental health care, improved quality of life, and reductions in depression and anxiety, utilization of primary care and emergency department services, and overall health care costs; Spanish-speaking patients have benefited disproportionately from the program in certain areas.

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