Patient Care Process
A federally qualified health center offers comprehensive, integrated medication therapy and disease management services to at-risk patients, leading to reductions in actual and potential adverse drug events, admissions, and readmissions; better chronic disease management and control; and high levels of patient satisfaction.
A rehabilitation hospital revamped its patient education and transition services to incorporate a variety of patient-centered, peer-led approaches, leading to enhanced patient engagement and self-efficacy and fewer readmissions.
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.
A multistakeholder statewide consortium increases the adoption and use of pharmacist-led medication therapy management services in federally qualified health centers, leading to better management of diabetes and hypertension and fewer adverse drug events.
A community paramedic works onsite at a homeless shelter during afternoon and evening hours 4 days a week during periods when an onsite primary care clinic is not open, significantly reducing unnecessary 911 calls and connecting shelter residents to primary care.
Patient and family advisors conduct regular rounds with patients and their family members on inpatient units and in the emergency department, contributing to a reduction in falls and to better performance on key patient experience metrics.
Patient and family advisors work with other stakeholders to redesign the structure and process for bedside change-of-shift reports, leading to more consistent use of the new approach.
Pharmacy teams provide comprehensive medication management services to at-risk patients at safety net clinics via video consultations, leading to better chronic disease outcomes, fewer emergency department visits and hospitalizations, and high levels of patient and provider satisfaction.
Pharmacists working as part of care teams in patient-centered medical homes assist at-risk patients in managing their medication regimens, leading to more knowledgeable and confident patients, better outcomes, lower costs, and high levels of patient satisfaction.
Replacing traditional visiting restrictions, a hospital’s “welcome” policy allows loved ones (including minors) to be with patients round-the-clock, leading to very positive feedback from patients, family members and friends, and hospital staff.