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Innovations

Primary Care–Based, Multidisciplinary Teams Provide Care Management Services to Complex Patients, Enhancing Patient Engagement and Reducing Hospitalizations 06/27/16

Multidisciplinary teams embedded within primary care practices provide care management and other support services to medically and psychosocially complex patients, enhancing patient engagement and self-management skills and reducing hospitalizations and emergency department visits.

Collaborative Health Education and Access Events Offer No-Cost Screenings and Navigation Services To Connect Lesbian, Gay, Bisexual, and Transgender Individuals With Medical Homes Offering Culturally Competent Care 12/19/14

Lesbian Health Initiative of Houston, Inc., creates a gateway to medical homes for lesbian, gay, bisexual, and transgender women and transgender men through a program that combines culturally competent outreach, education, screening, and patient navigation.

Regional Commission Made Up of Diverse Stakeholders Enhances Access to Coverage and Services for Low-Income Residents, Reducing Readmissions and Emergency Department Visits 11/04/14

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.

Culturally Tailored Chronic Disease Education Program Improves African American Patients' Self-Management Behaviors, Blood Pressure and Blood Glucose Control, and Quality of Life 09/17/14

This culturally tailored program educates minority populations with diabetes, hypertension, or overweight/obesity about appropriate management of these conditions.

State Provides Financial and Technical Support to Underserved Communities Designated as Health Enterprise Zones, Leading to Enhancements in Primary Care Capacity 03/11/14

The State of Maryland provides financial and technical support to five communities designated through a competitive bidding process as health enterprise zones, leading to an expansion of primary care capacity in these areas.

Community Cancer Coalition Employs Navigators Who Enhance Access to Free Colonoscopy Screening for Uninsured Rural Patients 01/17/14

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.

Mental Health Center Provides Integrated Primary Care and Care Coordination to Medicaid Beneficiaries With Severe Mental Illness, Enhancing Access to Services and Improving Outcomes 12/20/13

With support from State funding, a community mental health center provides integrated mental health, primary care, care coordination, and wellness services to Medicaid beneficiaries with severe and persistent mental illness, leading to better chronic disease outcomes.

Emergency Department Uses Tool To Identify At-Risk Patients in Need of HIV Testing, Leading to Same Number of Newly Diagnosed Patients with Fewer Screening Tests 12/18/13

An emergency department uses an eight-variable risk assessment tool to determine which patients should be tested for undiagnosed HIV, leading to the identification of the same number of HIV-positive patients as through universal screening, thus suggesting greater cost-effectiveness.

Peer Specialists in Federally Qualified Health Centers Enhance Access to Behavioral and Physical Health Support Services for Clients With Co-Occurring Medical and Mental Health Issues 12/13/13

Certified peer specialists provide emotional support, education, links to community services, and other support to individuals with co-occurring medical and mental health diagnoses at two Michigan federally qualified health centers, generating high levels of satisfaction and anecdotal reports of improvements in physical and mental health.

Foundation Develops Community-Based HIV Testing and Partnerships With Medical Homes, Leading to More Timely Linkages to Care for Newly Diagnosed Patients 11/25/13

A local foundation developed community-based testing programs and partnerships with medical homes to provide real-time linkages to HIV care to newly diagnosed patients and to support these patients in transitioning to care, nearly doubling the number of patients initiating treatment.
 

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