Chronic care

Innovations

Group Primary Care Visits Improve Outcomes for Patients With Chronic Conditions 02/29/08

Hill Physicians Medical Group offers 60- to 90-minute group appointments for patients with chronic conditions such as diabetes, hypertension, and chronic obstructive pulmonary disease, as well as menopause, prenatal care, and precolonoscopy; the program has led to improved outcomes for diabetes patients and anecdotal reports of higher patient and physician satisfaction and reduced downstream utilization.

Placing Mental Health Specialists in Primary Care Settings Enhances Patient Engagement, Produces Favorable Results Relative to Evidence-Based Care 02/26/08

An integrated care program places mental and behavioral health specialists in more than 50 primary care locations to treat patients ages 65 years and older with depression or anxiety and those who engage in risky alcohol use.

Computerized, Multilingual Visual Medication Schedule and Teach-Back Protocols Improve Anticoagulation Control for Low-Literacy Patients 02/26/08

A randomized clinical trial at San Francisco General Hospital used visual medication schedules and brief teach-back protocols in English, Spanish, and Cantonese to improve anticoagulant control among low-literacy patients in the public hospital's anticoagulation clinic.

Onsite Care Teams Enhance Access to Medical and Mental Health/Substance Abuse Services for Homeless Individuals 02/26/08

Penobscot Community Health Center provides onsite services at a community health clinic, with psychiatric and medical professionals offering primary care, disease management, mental health, and substance abuse services, along with referrals to additional mental health and other specialty services that may be needed.

Weight Management Program That Incorporates Mental Health and Chronic Disease Education and Screening Targets Low-Income Hispanic Children 02/25/08

The Lutheran Family Health Centers Network, in collaboration with its school-based health program at PS 24 in Brooklyn, NY, has developed a program known as Healthy Body/Healthy Mind (or Cuerpo Sano/Mente Sana in Spanish).

Community-Wide Collaboration Provides School-Based Mental Health Services to Students and Families in Impoverished, High-Crime, Urban Neighborhoods 02/25/08

A child mental health agency, the Boston Public Schools, and several other urban community service agencies have joined together to provide school-based mental health and other support services to students and their families living in neighborhoods plagued by poverty and crime.

Remote Assessment and Treatment via Telemedicine Combined With Onsite Case Management Enhance Access to Mental Health Services for Low-Income and Minority Students 02/25/08

In collaboration with several community partners, the University of Texas Medical Branch provides remote mental health assessment and treatment services via videoconferencing technology and onsite case management to low-income, minority, and other students and parents in seven school-based primary care clinics in the Galveston Independent School District.

Automated, Telephone-Based Interactive, Language-Appropriate Monitoring Engages and Improves Health Behaviors of Low-Income Diabetes Patients 02/22/08

The Automated Telephone Diabetes Management program, a part of the IDEALL project, provided automated telephone monitoring of individuals with poorly controlled type II diabetes who receive their care at four safety net clinics in San Francisco.

Nurse-Led Visits and Care Coordination Promote Self-Care and Improve the Health of Diabetic Adults With Severe Mental Illness 02/21/08

Psychiatric nurses work intensively with diabetic adults with severe mental illness over a 16-visit intervention to empower them to manage their diabetes more effectively.

Program Makes Staff More Sensitive to Health Literacy and Promotes Access to Understandable Health Information 02/21/08

The Health Literacy Collaborative of UnityPoint Health (previously Iowa Health System) educates staff on the importance of communicating health information clearly to patients and families regardless of reading ability, creates easy-to-understand materials based on patients' needs and preferences, and trains health care workers to use these materials with their patients.

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