Preventive care processes
Supported by mobile technology, trained health coaches and nurse care coordinators use home visits and telephone-based monitoring to identify and address declines in health status in recently discharged Medicare patients, leading to a significant reduction in readmissions and associated cost savings.
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.
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.
The Dentists' Partnership offers free oral health care to low-income individuals in exchange for community service, resulting in a 70-percent decline in emergency department visits for urgent dental conditions, a positive return on investment, and high levels of dentist and patient satisfaction.
A mobile clinic provides screening, education, coaching, and health navigation services to residents of four underserved communities, leading to the identification of many previously undetected chronic conditions, better blood pressure control, and a substantial return on investment.
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.
The Georgia Medicaid program expanded the definition of reimbursable services provided by mental health peer specialists to include physical health and wellness services, resulting in the training and certification of 175 such specialists to provide these services and in anecdotal reports of improved physical health outcomes among clients who receive the services.
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.
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.