Follow-up care

Innovations

Collaborative Health Education and Access Events Offer No-Cost Screenings and Navigation Services To Connect Lesbian, Gay, Bisexual, and Transgender Individuals With Medical Homes Offering Culturally Competent Care 12/19/14

Lesbian Health Initiative of Houston, Inc., creates a gateway to medical homes for lesbian, gay, bisexual, and transgender women and transgender men through a program that combines culturally competent outreach, education, screening, and patient navigation.

Spine Clinic Offers Same-Day Appointments and Immediate Physical Therapy for Uncomplicated Back Pain, Reducing Absenteeism, Followup Appointments, and Costs 12/19/14

Virginia Mason Medical Center created a spine clinic that provides rapid, efficient treatment for uncomplicated low back pain, with the goal of allowing patients to return to their jobs and other regular activities as soon as possible.

Culturally Tailored Group Meetings and Other Support Help Abused African-American Women Build Coping Skills and Reduce Depressive Symptoms, Suicidal Thoughts, and Suicide Attempts 11/05/14

A culturally tailored support group helps African-American women who are victims of intimate partner violence build coping skills, leading to reductions in depressive symptoms, levels of general distress, suicidal ideation, and suicide attempts.

Emergency Department–Based Asthma Clinic Improves Self-Management Behaviors and Reduces Acute Episodes for Low-Income, Inner-City Children and Teenagers 09/17/14

Children's National Health System has an emergency department–based clinic that serves low-income, minority children and teenagers with asthma.

Daily Text Messages and Nurse Followup Improve Self-Management Behaviors in Patients with Diabetes, Leading to Better Glycemic Control and Lower Costs 04/28/14

Daily automated text messages combined with nurse followup improved self-management behaviors among patients with diabetes, leading to significant improvements in glycemic control, fewer doctor visits, lower costs, and high patient satisfaction.

Community-Based Health Coaches and Care Coordinators Reduce Readmissions Using Information Technology To Identify and Support At-Risk Medicare Patients After Discharge 03/23/14

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.

Community Health Workers Embedded in Inpatient and Outpatient Clinical Teams Enhance Access to Primary Care and Improve Health Outcomes for Low-Income Patients 03/13/14

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.

State Medicaid Program Pays Additional Capitated Fee to Integrated Primary Care and Mental Health Homes, Leading to Better Outcomes and Lower Costs 03/01/14

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 Cancer Coalition Employs Navigators Who Enhance Access to Free Colonoscopy Screening for Uninsured Rural Patients 01/17/14

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.

Mental Health Center Provides Integrated Primary Care and Care Coordination to Medicaid Beneficiaries With Severe Mental Illness, Enhancing Access to Services and Improving Outcomes 12/20/13

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.

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