Chronic care

Innovations

Community Referral Liaisons Help Patients Reduce Risky Health Behaviors, Leading to Improvements in Health Status 08/11/08

A community health educator referral liaison receives physician referrals of patients with risky health behaviors; the liaison links patients with community resources, offers counseling and encouragement over the telephone, and provides feedback to the physicians.

Plan-Funded Team Coordinates Enhanced Primary Care and Support Services to At-Risk Seniors, Reducing Hospitalizations and Emergency Department Visits 08/08/08

Commonwealth Care Alliance developed a health plan that provides low-income, dually eligible, elderly enrollees in Massachusetts with a primary care team made up of a physician, nurse practitioner, and geriatric specialist who work out of the enrollee's primary care clinic.

Weight Loss Center Aims to Help Rural, Obese Children Improve Mental and Physical Health by Integrating Medical, Psychosocial, and Nutrition Services 08/04/08

The Pediatric Healthy Weight Research and Treatment Center provides multidisciplinary evaluation and treatment for overweight, low-income youth in eastern North Carolina.

School-Based Transition Program Connecting High-Risk Adolescents to Mental Health and Support Services Improves Academic and Familial Functioning 07/29/08

The Brookline Resilient Youth Team assists teenagers and their families who have recently experienced serious emotional disorders, medical issues, substance abuse, and/or other problems.

Mailed Reminders to Heart Attack Patients Improve Compliance With Beta Blocker Medication Regimen 07/28/08

Four health maintenance organizations send two reminder letters to encourage recent heart attack patients to take their beta blocker medication as prescribed and to renew their prescriptions as needed.

Comprehensive Heart Failure Program Enhances Adherence to Recommended Care and Reduces Hospital Readmissions 07/25/08

Baystate Medical Center's comprehensive heart failure management program incorporates tools and processes that ensure the provision of all necessary components of care, leading to increased adherence to recommended care and reduced heart failure readmission rates.

Transition Home Program Reduces Readmissions for Heart Failure Patients 07/23/08

The Transition Home for Patients with Heart Failure program incorporates a number of components to ensure patients a safe transition to home or another health care setting, leading to fewer readmissions.

Solo Physician's Use of Virtual and Phone Visits, Same-Day Appointments, and Extended In-Person Visits Leads to High Patient Satisfaction and Improved Chronic Disease Outcomes 07/18/08

A solo family practitioner provides 24-hour-a-day, 7-day-a-week access to care for her patients through liberal use of “virtual” or e-mail visits, telephone calls, same-day appointments, and extended office visits.

Community Health Collaborative Reduces Inappropriate Emergency Department Use by Providing Access to Health Care, Social Support for Low-Income Clients 07/18/08

A community health collaborative helps vulnerable populations secure and retain insurance coverage, access primary care, and connect to a medical home, leading to fewer emergency department visits, higher provider revenues, and high levels of provider satisfaction.

Community Coalition Connects Medical Practices to Community Resources, Leading to Improved Asthma and Diabetes Outcomes in At-Risk Populations 07/18/08

King County Steps to Health connected medical practices to community resources by encouraging organizations to work together to identify common messages, leverage resources, and develop programs for populations at risk for diabetes, asthma, and obesity.

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