The Advanced Illness Palliative Care program is a multidisciplinary initiative that provides care management and palliative care to chronically or terminally ill veterans in their homes via telehealth technology.
The AIDS Care Project increases access to free and low-cost acupuncture, Chinese herbal medicine, and shiatsu for underinsured Boston-area residents with human immunodeficiency virus/acquired immunodeficiency syndrome and other conditions.
Ethica Health and Retirement Communities developed a falls management program, the cornerstone of which is an interdisciplinary “falls team” at each nursing home that regularly assesses residents for risk of falling and develops intervention plans for those found at high risk.
Work Healthy brought together an interdisciplinary team of certified nurse practitioners, health educators, and community health workers to provide onsite health education, health promotion, and primary care services to low-income, uninsured workers in the mushroom industry.
Transitions coaches encourage recently hospitalized Medicare patients with complex care needs to assert a more active role in their posthospital care, leading to fewer readmissions and lower costs.
A nurse-guided, patient-centered approach combines ongoing peer support from a trained elder with home visits and followup phone calls from an advanced practice nurse for unpartnered, elderly patients who are discharged from the hospital after a heart attack or bypass surgery. The program is intended to encourage compliance with medication regimens and recommended lifestyle changes, with the goal of reducing hospital readmissions. A 247-patient randomized controlled trial found that the program improved adherence to medical recommendations and reduced hospitalizations due to cardiac-related complications but failed to reduce overall hospital readmissions.
Community clinics use the Toyota “Lean” rapid cycle process improvement system to enhance efficiency and productivity, leading to a significant increase in revenues.
Web-based communities allow patients with a variety of life-changing illnesses to record functional outcomes, share these data securely with clinicians and caregivers, and communicate with similar patients for support and learning.
Kaiser Permanente Colorado developed a computerized alert system to notify pharmacists when elderly patients are prescribed potentially inappropriate medications; alerted pharmacists consult with the physicians to discuss the prescription, leading to a reduction in inappropriate prescribing.
Group visits allow substantially more patients with dementia to be served with only a modest increase in clinician time, leading to high levels of patient, caregiver, and provider satisfaction.