Chronic care

Innovations

Nurse Case Managers Offer Low-Resource Transitional Care Services, Reducing Readmissions for At-Risk, Community-Dwelling Veterans in Remote Areas 01/25/13

Nurse case managers at a Veterans Affairs hospital provide inhospital and post-discharge, telephone-based support to at-risk, community-dwelling patients and their caregivers, leading to better care transitions, fewer readmissions, and substantial cost savings.

State Partnership Supports Quality Improvement in Pediatric Practices, Leading to More Evidence-Based Care, Better Care Coordination, and High Satisfaction in Participating Practices 01/09/13

A State-based, public–private partnership supports quality improvement in pediatric practices, leading to greater adherence to evidence-based care and improved care coordination for children and adolescents, and to higher staff satisfaction in participating practices, and highly rated quality of care for children.

Teams of Diabetes Educators Regularly Visit Rural Clinics to Coach African-American Patients, Leading to Better Glycemic Control and Potential Cost Savings 11/19/12

A traveling team of certified diabetes educators (including a nurse, pharmacist, and dietitian) regularly visits rural clinics to help coordinate diabetes care with clinicians and educate and coach African-American patients with diabetes, leading to improved glycemic control and the potential for meaningful cost savings.

Community-Based Oncology Practice Redesigns Processes Based on Patient-Centered Medical Home Model To Enhance Access, Improve Quality, and Reduce Costs 11/12/12

A community-based oncology practice's patient-centered medical home model features oncology-specific information technology, a standardized assessment, multidisciplinary care plan, patient navigators, telephone triage line, patient education and engagement, and ongoing performance monitoring, leading to improvements in access, quality, and costs.

Assessment Tool Helps Clinicians Understand and Address Quality-of-Life Concerns for Those With Diabetes, Generating Positive Feedback From Clinicians and Patients 11/01/12

Before seeing their provider, patients with diabetes complete an easy-to-use assessment tool that helps identify and address their biggest quality-of-life concerns, generating overwhelmingly positive feedback from patients and clinicians.

State Automatically Enrolls Low-Income Children in Medicaid Based on Information From Food Program Application, Reducing Number of Uninsured and Administrative Costs 10/29/12

Using a data-matching program, the state of Louisiana allows qualified, low-income children to be automatically enrolled in Medicaid based on information submitted on applications to the state's Supplemental Nutrition Assistance Program, enhancing access to Medicaid coverage and health care services and significantly reducing administrative costs.

State Legislation Supports Professional Development of Community Health Workers, Leading to Greater Professional Recognition, Enhancements in Training, and Funding 10/15/12

An alliance of government and not-for-profit agencies aided the passage of various legislative provisions in Massachusetts designed to create a more stable, systemic role for community health workers, leading to greater professional recognition, an expanded workforce and training infrastructure, and increased funding of services.

Physician Practices Use Software-Facilitated System to Complete Medicare Annual Wellness Visit, Improving Preventive Care and Generating High Satisfaction 09/21/12

Primary care practices use a software-facilitated process to proactively schedule and efficiently complete required components of Medicare's Annual Wellness Visit and to identify and address care gaps, leading to improvements in the provision of preventive services and high physician and patient satisfaction.

Hospital–Community Organization Partnership Uses Culturally Competent Community Health Workers To Support Latino Families With Asthmatic Children, Reducing Hospitalizations and Emergency Department Visits 09/10/12

In a partnership between a hospital and four community-based organizations, bilingual community health workers help low-income, predominantly Latino families with asthmatic children better manage the disease, leading to fewer asthma-related symptoms, hospitalizations, emergency department visits, and missed school days.

Self-Directed Budget for Health and Other Services Enhances Ability of Those with Mental Illness to Function and Live Independently 08/24/12

A state-funded program gives individuals with mental illness a quarterly allowance for mental health and wellness services that can be spent at their own discretion, allowing them to spend more time living in the community and to function more effectively.

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