Chronic care

Innovations

At-Home Palliative Care for Veterans Enhances Medication Adherence and Connections With Families and Providers, While Also Lowering Costs 02/20/08

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.

AIDS Care Project Makes Acupuncture Treatment Accessible to People Living With HIV/AIDS 02/19/08

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.

Interdisciplinary Team Identifies and Addresses Risk Factors for Falls Among Nursing Home Residents, Leading to Fewer Falls and Less Use of Restraints 02/18/08

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.

Onsite Clinic Staffed by Bilingual, Culturally Competent, Interdisciplinary Team Brings Health Education and Primary Care to Low-Income, Uninsured Workers 02/15/08

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.

Transition Coaches Reduce Readmissions for Medicare Patients With Complex Postdischarge Needs 02/14/08

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.

Peer Coaching Combined With Nurse Outreach Improves Adherence to Medical Recommendations Among Elderly Cardiac Patients Who Live Alone Following Discharge 02/12/08

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.

Adoption of Rapid Cycle Improvement Process From Toyota Increases Efficiency and Productivity at Community Health Clinics 02/08/08

Community clinics use the Toyota “Lean” rapid cycle process improvement system to enhance efficiency and productivity, leading to a significant increase in revenues.

Online Communities Foster Data-Sharing, Communication, and Learning Among Patients With Neurologic and Other Chronic Diseases 02/06/08

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.

Group Visits Expand Capacity to Serve Dementia Patients and Caregivers, Result in High Levels of Patient and Provider Satisfaction 01/28/08

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.

Back Care Program That Emphasizes Pain Control and Behavioral Modifications Reduces Pain Levels and Lost Workdays 01/28/08

A health plan-led program that encourages patients with chronic low back pain to increase exercise, use appropriate medications, and reduce stresses on the back led to reduced pain levels and absenteeism.

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