Chronic care

Innovations

Interim Methadone Maintenance Program Reduces Heroin Use and Increases Treatment Entry Rates for Addicts Awaiting Comprehensive Services 05/02/08

Operating within U.S. Federal regulations, the Baltimore Interim Methadone Maintenance program provides interim care (in the form of daily methadone with emergency counseling) to heroin addicts awaiting placement for comprehensive methadone treatment programs.

Individualized, In-Home Program Identifies and Addresses Environmental Problems That Can Worsen Asthma Control 04/30/08

A health plan's individualized, in-home, environmental asthma intervention program targets all pediatric members with confirmed allergies to indoor allergens and symptomatic asthma. During multiple in-home visits, trained asthma counselors provide education, perform an environmental assessment, demonstrate intervention equipment, devise a written care plan, and assess and address psychosocial issues.

Formalized Communication Between Rural Home Health Agency Nurses and Physicians Leads to Increased Use of Home Health Services, Fewer Inpatient Admissions 04/28/08

A rural home health agency formalized oral and written communication processes with physicians, using specific communication tools to ensure that ongoing patient needs are being met; the program led to an increase in the use of home health services and a concomitant decline in inpatient admissions among home health patients.

Health Plan–Financed, Nurse-Led Care Coordination Improves Quality of Care and Reduces Costs for Latinos With Chronic Illnesses and Disabilities 04/21/08

A community-based primary care clinic uses nurses to provide culturally competent care coordination to Latino patients with chronic illnesses and disabilities, leading to greater provision of recommended care, lower health care costs, and enhanced self-management capabilities.

Bilingual, Bicultural Asthma Intervention Program Significantly Improves Outcomes for Poor, Inner-City Youth 04/07/08

The El Rio Inner-City Asthma Intervention Program is a comprehensive bilingual, bicultural program that primarily serves low-income, inner-city Latino children with moderate or severe persistent asthma.

Integrating Behavioral Health and Nutrition Services Into Primary Care Clinics Significantly Reduces Mental Health-Related Hospitalizations for Staff-Model Health Maintenance Organization 03/28/08

A health maintenance organization integrated mental and behavioral health care and nutrition services with primary care delivery, leading to a more than 50-percent reduction in mental health–related hospitalizations.

Enhancements to Interpreter Program Lead to Better Productivity for Interpreters, More Depression Screening, and Potential Reduction in Readmissions for Non–English-Speaking Patients 03/24/08

Cambridge Health Alliance enhanced its round-the-clock interpreter services by tracking key indicators that gauge the quality of these services; analyses of these data led to significant improvements in the program's telephone-based services and staff efficiency and the decision to implement depression screening in patients with limited English proficiency.

Program Uses "Pathways" to Confirm Those At-Risk Connect to Community Based Health and Social Services, Leading to Improved Outcomes 03/24/08

The Pathways Model employs community health workers who connect at-risk individuals to evidence-based care through the use of individualized care pathways designed to produce healthy outcomes; implementation of this model in Richland County, OH, resulted in increased services to at-risk women and a decline in the rate of low birth weight babies.

Disease Management Programs Improve Adherence to Evidence-Based Processes and Outcomes by Targeting Sickest Patients and Working Closely With Physicians 03/14/08

A hospital-based outpatient disease management program serves patients with asthma, chronic heart failure, and diabetes and offers smoking cessation services to smokers. Unlike traditional disease management programs, this initiative heavily involves physicians in the initial referral and throughout the process and targets services toward the sickest patients (rather than to all patients with the condition).

Pediatric Center Offers Coordinated, Culturally Appropriate Services, Increasing Access to Comprehensive Care for Low-Income Children With Special Health Care Needs 03/07/08

A pediatric center provides comprehensive, coordinated services within a primary care medical home for low-income and immigrant children with special health care needs.

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