Chronic care

Public health nurses provide case management services to women with one or more chronic conditions who receive Temporary Assistance for Needy Families, leading to enhanced access to mental health services, fewer depressive symptoms, and improved functional status.

Low-income, African-American, rural HIV patients receive regular self-written text message reminders that encourage them to regularly access HIV/AIDS primary care, leading to greater retention in care and enhanced quality of life.

Two safety net clinics offered low-income Hispanic patients with both diabetes and depression culturally appropriate care (including medication and/or psychotherapy) and ongoing support led by trained, bilingual social workers, leading to improvements in medication adherence, depression-related symptoms, and patient satisfaction.

An integrated health system offered a customized suite of interactive, Web-based education and tools to individuals with diabetes, leading to high levels of engagement, enhanced knowledge and attitudes about the disease, and improvements in hemoglobin A1c levels.

Community-based primary care physicians receive support from specialist physicians and a multidisciplinary team, leading to enhanced access to high-quality care for HIV-positive patients.

Nurses remotely monitor key indicators of end-stage renal disease patients and intervene as appropriate, leading to less inpatient and emergency department use and higher quality of life.

Individuals with depression and/or other mood disorders log and track their daily mood through a mobile phone application, leading to higher adherence than with paper-based tools, better treatment decisions, and positive feedback from patients and clinicians.

A local foundation supports schools, churches, local governments, and employers in eight rural Mississippi counties in addressing the area's obesity epidemic through programs to promote access to healthy food and opportunities for physical activity, leading to anecdotal reports of improvements in health-related behaviors and outcomes.

A hospital screens all cardiac inpatients for depression and anxiety and initiates treatment for them as appropriate, leading to improvements in cardiac symptoms and mental health.

Culturally appropriate videos provide first-person narratives of patients living with hypertension, leading to significant improvements in blood pressure among low-income, inner-city African Americans with previously uncontrolled hypertension.