Chronic care


Kidney Transplant Center Required Completion of Education Class Prior to Medical Assessment, Leading to More Patients Completing Evaluation 05/21/12

A transplant center established a mandatory education session for newly referred patients, leading to a significant increase in the percentage of patients (particularly African Americans and people of lower socioeconomic status) completing the enrollment process.

School District Uses Policies and Related Programs to Improve Health, Behavior, and Academic Performance of Students with Asthma and Reduce Absenteeism 05/21/12

A school district's multifaceted, collaborative initiative to reduce the impact of asthma includes multiple policies and subsequent programs such as electronic monitoring, case management, and stakeholder-specific education, leading to fewer asthma-related absences and better academic performance, behavior, health, and quality of life for students with asthma.

Statewide Program Supports Medical Homes Through Multidisciplinary Teams, Easy Access to Information, and Incentives, Leading to Lower Costs and Better Care 05/18/12

A statewide program supports physician practices through multidisciplinary community-based health teams, preventive health expertise, easy access to needed information via electronic systems, and financial incentives, leading to lower utilization and growth in health care spending and enhanced provision of appropriate services.

State Agency Promotes Integrated Mental Health and Addiction Treatment for Co-Occurring Disorders, Leading to Better Access and Positive Outcomes 05/17/12

A state mental health and addiction services agency implemented policies to promote integrated treatment for those with both mental health and substance use disorders, leading to enhanced access to high-quality services and positive patient outcomes.

Culturally Competent Disease Management Improves Self-Monitoring and Blood Pressure Control in Hypertensive African Americans 02/09/12

A health plan–sponsored disease management program targeting African Americans combines home blood pressure monitoring with culturally competent education and counseling, leading to better self-monitoring and blood pressure control.

Outreach Workers Connect Low-Income Individuals Living in Rural Areas to Home- and Community-Based Services, Reducing Costs and Nursing Home Placements 02/01/12

Community outreach workers identify residents at risk of nursing home placement and arrange for them to receive appropriate home- and community-based services, leading to fewer nursing home placements and significant cost savings.

Medical Student–Run Primary Care Clinic Offers Valuable Training to Future Physicians and Enhances Access to Care for Low-Income Patients 01/20/12

Medical students operate a free primary care health clinic for visitors to a large, local soup kitchen, gaining invaluable experience and providing patients with medical care they would otherwise likely go without.

Care Coordination, Peer Support, and Discretionary Fund Improve Quality of Life and Reduce Costs for Adults with Serious Mental Illness 01/14/12

Intensive, person-centered case management, peer support, and a discretionary fund for adults with serious mental illness leads to better access to treatment, job training, and employment; fewer suicide/self-harm attempts, hospitalizations, incarcerations, and days of homelessness; and lower mental illness-related costs.

Standardized Order Bundles and Ongoing Care Coordination Expedite Testing and Specialty Consults for Primary Care Patients With Common Conditions 01/14/12

Primary care physicians order standardized bundles of tests and specialty referrals for common diagnoses, which are then managed by a care coordination team, resulting in expedited patient care and high physician satisfaction.

Pharmacists Support Employees and Physicians in Managing Chronic Conditions, Leading to Better Care and Disease Control, Lower Costs, and Higher Productivity 01/10/12

Pharmacists provide ongoing chronic care management support to employees and their physicians, leading to greater adherence to recommended care processes and self-management behaviors, lower costs, higher productivity, and a significant return on investment.


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