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.
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.
A specially designed pill-bottle system supplied visual and auditory reminders to patients, along with telephone reminders after missed doses and progress reports to be shared with providers; the program significantly increased medication adherence in those with uncomplicated hypertension.
A transitional care program that identifies frail elderly patients in the hospital and provides them with in-home support after discharge significantly reduces readmissions and emergency department visits.
Pharmacist coaches meet periodically with employees who have diabetes to assess health, monitor medications, and strengthen self-management skills, leading to better blood glucose and blood pressure control, greater adherence to recommended care processes, and lower overall health care costs.
Individuals with asthma receive weekly reports via e-mail that provide detailed information on the use of rescue medications (tracked by a device attached to the rescue inhaler), leading to better asthma control, fewer asthma-related symptoms, enhanced knowledge and awareness, and greater adherence to preventive medication regimens.
An integrated health plan provider system sends every member due for colorectal cancer screening an in-home fecal immunochemical test kit and conducts various folllowups with those who do not return a completed specimen for processing; the program led to a near doubling of screening rates over a 5-year period.
Ongoing case management, education, and peer support to low-income parents struggling with mental health and substance abuse disorders focuses on reducing the stigma associated with illness, increasing positive family interaction, and identifying and addressing cognitive and behavioral problems in children. Evidence suggests the program leads to less mental health–related stigma and stress, improved parenting skills and social support networks, few psychiatric hospitalizations, enhanced access to needed services for children, and many lasting family reunifications.
With the support of the Ministerial Alliance and local churches, a collaboration between an integrated health system and the YMCA offered a 6-month program combining exercise classes, nutrition and wellness programs, incentives, and case management support, leading to improved exercise and eating habits and lower blood pressure and body mass index among overweight and obese African-American women.
Regular reminders via text message enhance adherence to medication regimens and reduce risk of organ rejection in pediatric liver transplant patients.