Chronic care

Innovations

Case Managers Remotely Monitor Chronically Ill Medicare Beneficiaries Each Day, Reducing Mortality and Costs 01/09/12

Case managers remotely monitor Medicare beneficiaries with chronic conditions via a messaging device that asks and records answers to disease-specific and general health questions each day, leading to lower mortality and costs.

System-Integrated Program Coordinates Care for People With Advanced Illness, Leading to Greater Use of Hospice Services, Lower Utilization and Costs, and High Satisfaction 12/20/11

The Advanced Illness Management program supports Medicare patients with advanced illness and their families in making patient-centered decisions, leading to greater use of hospice care, lower inpatient and ambulatory utilization and overall care costs, and high levels of patient, family, and physician satisfaction.

Mobile Clinic and In-Home Educator Generate Small, Short-Term Increases in Symptom-Free Days in Inner-City Preschool Children With Asthma But No Improvements in Other Key Outcomes 12/19/11

A mobile pediatric asthma clinic combined with home visits generated small, short-term increases in symptom-free days in preschool children, and no improvements in other key outcomes.

Interactive Videoconferences Increase Primary Care Provider Knowledge and Confidence, Leading to Enhanced Access to Specialty Care for Low-Income Urban Patients 12/09/11

Series of interactive videoconference sessions provide didactic and interactive instruction in specialty care to primary care clinicians in community-based clinics, boosting their knowledge and confidence in these areas, and enhancing access to specialty care for their low-income, urban patients.

Church-Health System Partnership Facilitates Transitions From Hospital to Home for Urban, Low-Income African Americans, Reducing Mortality, Utilization, and Costs 11/29/11

A partnership between a large health system and 512 churches supports the transition from the hospital back into the community, leading to lower mortality, health care utilization, and health care costs and to higher satisfaction with hospital care.

Community Pediatricians Use Software to Diagnose and Manage Attention-Deficit/Hyperactivity Disorder, Leading to Improvements in Symptoms 11/26/11

Pediatricians in community practice use computer software and a manual to diagnose and manage attention-deficit/hyperactivity disorder, leading to significant improvements in symptoms.

Hospital-Based Social Workers Follow Up With Recently Discharged Older Adults to Resolve Transition Problems, Reducing Readmissions and Deaths 11/11/11

Hospital-based social workers support recently discharged older patients and their caregivers in resolving problems related to their transition back home, leading to enhanced patient and caregiver knowledge, better attendance at followup appointments, and fewer readmissions and deaths.

Partnership Supports Patients With Dementia and Their Caregivers Through Care Coordinator Team, Leading to Improved Psychosocial Outcomes 11/11/11

Through a partnership between the Veterans Administration and the Alzheimer's Association, a two-person care coordinator team provided support to patients with dementia and their caregivers over a 12-month period. The program led to improved psychosocial outcomes for veterans and caregivers, fewer readmissions and institutional placements, enhanced access to outpatient services, and higher overall health care costs.

Trained Paramedics Provide Ongoing Support to Frequent 911 Callers, Reducing Use of Ambulance and Emergency Department Services 11/10/11

An emergency medical system provider uses advance practice paramedics to provide in-home and telephone-based support to patients who frequently call 911, reducing the use of ambulance and emergency department services.

Coordinated Treatment and Support Enhance Access to Care for Veterans With Post-Traumatic Stress Disorder and Traumatic Brain Injury and Their Families 11/02/11

A partnership between academic medicine and a major-league sports team enhances access to care by providing treatment and support to veterans who suffer from traumatic brain injury and posttraumatic stress disorder and their families, generating high levels of patient satisfaction.

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