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