Patient Care Process
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.
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.
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.
The Missouri Medicaid Health Home program provides capitated payments to primary care and mental health medical homes that adopt an integrated staffing model that allows patients to receive both medical and mental health care, leading to better health outcomes and lower utilization and costs.
Community health workers provided culturally tailored workshops and one-on-one counseling and support to Filipino Americans at high risk of cardiovascular disease, leading to greater adherence to medication regimens, better attendance at scheduled appointments, improved blood pressure control, and lower body mass index.
Hospitals use a real-time location system to track employees, patients, and/or major pieces of equipment, leading to lower equipment costs, better infection control processes, faster room turnaround, and high levels of patient, physician, and staff satisfaction.
A hospital uses round-the-clock pulse oximetry monitoring to identify patients who exhibit early signs of deterioration and automatically notify their nurse, leading to reductions in rescue events and transfers to the intensive care unit.
A State-led accountable care collaborative provides comprehensive, coordinated care to Medicaid beneficiaries through primary care medical homes, reducing use of inpatient, imaging, and emergency department services, and generating estimated savings of $6 million for the State.
A group of 14 long-term care facilities cede control of immunization policies to a regional pharmacy, leading to a significant increase in influenza vaccination rates among facility workers.