Home telemonitoring did not improve blood pressure or blood glucose control in diabetes patients with out-of-range values.
A physician-led practice offers integrated, coordinated care under capitated contracts to high-risk, moderate- and low-income seniors enrolled in Medicare Advantage plans, leading to high levels of adherence to recommended screening services, good blood glucose control among patients with diabetes, below-average use of inpatient services, high patient satisfaction, and improvements in patient access to medications.
A regional health commission made up of a diverse group of stakeholders promotes various activities and policies to support the safety-net health system, enhancing access to coverage, medical and dental care, and medical homes, and reducing readmissions and inappropriate use of the emergency department.
The Quality Health Network used an inclusive design process and invested significant time and resources in promoting and supporting use of its health information exchange, which serves patients and providers in seven counties in rural western Colorado.
Primary care practices leverage information technologies to identify patients at risk of undiagnosed hypertension and schedule them for automated office blood pressure measurement, reducing the likelihood of remaining undiagnosed by more than 70 percent.
After being briefed by hospitalists, primary care physicians meet or talk by phone with patients who have complex medication regimens at or soon after discharge, leading to a significant reduction in medication discrepancies.
Community health workers embedded in clinical teams in medical offices and hospitals support low-income patients in setting and achieving health-related goals and accessing needed medical and community-based services, leading to better communication and access to postdischarge primary care, increased patient activation, fewer readmissions and depression-related symptoms, and positive feedback from patients.
A hospital-affiliated physician group offers modest performance-based incentives to salaried physicians, leading to sustained improvements in performance on a broad array of quality-related metrics.
A community cancer coalition employs navigators who work with community health centers in rural areas to identify those in need of colorectal cancer screening via colonoscopy and facilitate access to such screening, leading to more referrals and screenings and to more cancers and precancerous polyps being detected and treated.
A nonprofit, community-based organization matches uninsured and underinsured patients with physicians, hospitals, and other providers who agree to serve them at reduced fees and provides various sources of support to both providers and patients, leading to enhanced access to care and fewer emergency department visits.