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.
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.
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.
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.
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.