A nonprofit, community-based organization matches uninsured and underinsured patients with physicians, hospitals, and other providers who agree to serve them at reduced fees and provides various sources of support to both providers and patients, leading to enhanced access to care and fewer emergency department visits.
Master's-level social workers operating out of a centralized department support primary care and specialty clinic patients in dealing with psychosocial and environmental issues, leading to high levels of patient/caregiver and practitioner satisfaction, improvements in patients' well-being and self-management skills, and reductions in resource use.
A safety net hospital employs a software application that uses electronic health record data and predictive modeling to identify and allocate scarce resources to high-risk patients, leading to fewer readmissions and lower costs.
The combination of a small financial incentive and patient education leads to a modest, short-lived increase in physician visits, but has no effect on blood pressure control or on racial and ethnic disparities in management and control of hypertension.
A partnership between a hospital and retail pharmacy company provides inhospital and postdischarge support to patients at high risk of readmission, leading to fewer readmissions and high levels of patient satisfaction.
The State of Connecticut offers employees, retirees, and dependents significant financial incentives to access appropriate care and engage in their health, leading to high participation rates, more appropriate utilization of health care resources, better medication adherence, and slower growth in costs.
A collaborative initiative features standardized care elements and fixed per-patient payments for treatment of depression in the primary care setting, leading to high rates of remission and response to treatment and high levels of provider satisfaction.
Patients with Crohn's disease reported information on nine observations of daily living (cues about health experienced in everyday living) using applications on a tablet computer, leading to more tracking of symptoms and health-related behaviors, better patient self-management and patient-provider communication, and high levels of patient satisfaction.
Nurse case managers at a Veterans Affairs hospital provide inhospital and post-discharge, telephone-based support to at-risk, community-dwelling patients and their caregivers, leading to better care transitions, fewer readmissions, and substantial cost savings.
A traveling team of certified diabetes educators (including a nurse, pharmacist, and dietitian) regularly visits rural clinics to help coordinate diabetes care with clinicians and educate and coach African-American patients with diabetes, leading to improved glycemic control and the potential for meaningful cost savings.