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.
The MyRx Medication Adherence Program offers culturally and linguistically tailored medication management and health education to seniors with hypertension or diabetes who were living in the community.
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.
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.
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.
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.
A county-based accountable care organization integrates medical, behavioral health, and social services and assigns a care coordinator to newly enrolled Medicaid beneficiaries to promote use of appropriate services, leading to fewer readmissions and emergency department visits and lower costs.
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 statewide, multipayer pilot program provides technical and financial support to physician practices interested in becoming patient-centered medical homes, leading to all participating practices being recognized as medical homes and to anecdotal reports of better access and higher quality.