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.
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.
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 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.
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 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.
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.
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.
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.
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.