The Marshfield Clinic is using electronic tools to facilitate care process redesign for patients with chronic illnesses, leading to enhanced quality and access to care, fewer hospitalizations and adverse events, and lower costs.
A computer-assisted patient assessment system allows patients who have severe mental illness to document important clinical information before their scheduled appointment with a clinician. A printout of answers to the assessment system is given to the clinician to use during the session.
Teams of primary care providers, supported by information technology, address gaps in care for a defined panel of patients, leading to greater adherence to evidence-based practices and improved outcomes.
Patients with chronic illnesses communicate with and receive real-time feedback from providers on at least a daily basis using customized mobile phone software, leading to better adherence, increased peak flow assessments, and fewer emergency department visits and missed school days.
A plan-sponsored, pharmacist-led prescription and over-the-counter medicine review program at a local supermarket chain helps identify potentially harmful medication interactions, reduces falls, and enhances medication compliance among Medicare beneficiaries.
Resident-Assisted Montessori Programming (RAMP) is a peer leadership program in which patients in the early stages of dementia are trained to lead group activities with their peers who have more advanced dementia. Using principles of the Montessori learning method, RAMP teaches early-stage patients to use their strengths, such as procedural memory, to engage patients in meaningful social roles.
The Sutter Care Coordination Program combines chronic care and disease management to address the medical and psychosocial needs of individuals with multiple chronic conditions.
CarePartners, a donated care program, matches uninsured Maine residents with primary care physicians who are willing to care for up to 10 patients for free. Case managers help enrollees obtain needed services, including hospital care, specialist services, and free or low-cost drugs through prescription assistance programs.
Remote diabetic retinopathy screening using the Eye Picture Archive Communication System digital ocular imaging software facilitated prompt retinopathy diagnosis in California's Central Valley, an area where many residents are poor and uninsured and diabetes is a major health concern.
Essentia Health Heart and Vascular Center created a heart failure program combining chronic care and disease management principles to improve outcomes and reduce costs associated with heart failure care.