Chronic care

Innovations

Electronic Health Record–Facilitated Care Process Redesign Enhances Access to Care, Reduces Hospitalizations and Costs for Patients With Chronic Illnesses 01/08/08

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.

Computerized, Previsit Self-Assessment Improves Care of Patients With Mental Illness 01/04/08

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.

Team-Based Ownership Over Defined Patient Panels Supported by Information Technology Enhances Provision of Evidence-Based Care 12/27/07

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.

Daily Patient-Provider Communication and Data Transfer Using Mobile Phones Improves Outcomes and Reduces Costs for Teens With Chronic Asthma 12/20/07

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.

Pharmacist-Led, Grocery Store–Based Medication Review Reduces Falls and Enhances Compliance for Medicare Managed Care Members 12/20/07

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.

Peer Leaders Facilitate Social Engagement Among Dementia Patients in Long-Term Care Facilities 12/20/07

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.

Chronic Care and Disease Management Improves Health, Reduces Costs for Patients With Multiple Chronic Conditions in an Integrated Health System 12/20/07

The Sutter Care Coordination Program combines chronic care and disease management to address the medical and psychosocial needs of individuals with multiple chronic conditions.

Donated Care Program Enhances Access to Ongoing Care for Uninsured Patients, Resulting in Significant Reductions in ED Visits, Hospitalizations, and Costs 12/19/07

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 Retinal Screening Facilitates Diagnosis and Treatment of Retinopathy for Poor and/or Uninsured Patients With Diabetes in Rural California 12/18/07

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.

Heart Failure Disease Management Improves Outcomes and Reduces Costs 12/14/07

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.

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