Chronic care

Innovations

Periodic, Nurse-Initiated Telephone Contact Provides Quality Followup Care to Infants With Lung Disease in Rural Areas 01/22/08

A nurse specialist maintains regular telephone contact with the primary caregivers and health care providers of premature infants with chronic lung disease who are discharged from the hospital.

Enhanced Posthospitalization Services Prove Popular With the Severely Mentally Ill and Their Providers 01/22/08

La Cheim Behavioral Health Services began offering a series of posthospitalization meetings and support services for “alumni” who had achieved their therapeutic goals in partial hospitalization or intensive outpatient therapy.

Onsite Nurses Manage Care Across Settings to Increase Satisfaction and Reduce Cost for Chronically Ill Seniors 01/21/08

Specially trained nurses work with primary care physicians in their offices to improve the quality and efficiency of care for seniors with multiple chronic illnesses by coordinating care, facilitating transitions in care, and acting as the patient's advocate across health care and social settings.

Nurse-Led Assessment and Tailored Intervention Did Not Improve Adherence to Medication Regimens in HIV/AIDS Patients 01/18/08

A nurse-led program did not improve adherence to antiretroviral medications for patients with human immunodeficiency virus who are either homeless or live in marginal housing.

Health Coach Program in a Medical Group Improves Self-Care and Decreases Readmissions for High-Risk, Chronically Ill Patients 01/17/08

Dartmouth-Hitchcock Clinic assigned health coaches to high-risk chronic disease patients to provide instruction regarding health care needs over the phone, during office visits, and in group classes; the program reduced readmission rates and costs among elderly patients.

Wireless Messaging System Has No Impact on Blood Glucose Levels, but Patients Believe It Improves Quality of Care 01/17/08

The University of Washington Physician's Network developed a wireless, pager-based messaging system to help diabetic patients better manage their condition. An evaluation of the initiative found that it had no impact on blood glucose levels, although blood pressure improved.

Postdischarge Care Management Integrates Medical and Psychosocial Care of Low-Income Elderly Patients 01/16/08

An interdisciplinary care management program that integrates medical and social care for low-income elderly patients with chronic illnesses reduces care costs and improves self-reported health status.

Periodic Home Visits, Specialist Visits, and Followup Enhances Access and Improves Outcomes for Low-Income Children With Asthma 01/15/08

A pediatric asthma management program led to a significant decline in the percentage of patients with moderate to severe asthma, improved quality of life, and sizable decreases in hospitalizations and costs.

Mental Health Court Links Eligible Offenders With Treatment and Monitoring, Reducing Recidivism, and Improving Outcomes 01/15/08

The Brooklyn Mental Health Court links eligible defendants to long-term treatment and monitoring of their mental health problems as an alternative to incarceration. Early evidence suggests that the program has been successful in reducing recidivism, homelessness, psychiatric hospitalizations, alcohol use, and substance abuse.

Better Integration of Home Health Aides Into the Health Care Team Improves Patient Functionality 01/11/08

A team-building program at the largest home care agency in the country integrated home health aides into the health care team and resulted in enhanced functional status for patients, including being better able to move independently from a bed to a wheelchair or chair and better able to walk without support.

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