Transitions between settings
Specially trained nurses work with primary care physicians in their offices to improve the quality and efficiency of care for seniors with multiple chronic illnesses by coordinating care, facilitating transitions in care, and acting as the patient's advocate across health care and social settings.
An interdisciplinary care management program that integrates medical and social care for low-income elderly patients with chronic illnesses reduces care costs and improves self-reported health status.
A partnership between a hospice organization and an 11-location multispecialty group practice places palliative care nurses in primary care clinics to monitor dying patients' medical and social care needs, coordinate community services, and discuss end-of-life issues.
A rapid response team defuses crisis situations for children with complex behavioral needs.
An evidence-based teamwork and communication program implemented in the labor and delivery unit of Madigan Army Medical Center led to an improved care process.
The Sutter Care Coordination Program combines chronic care and disease management to address the medical and psychosocial needs of individuals with multiple chronic conditions.
The Migrant Clinicians Network Prenatal Care Program seeks to ensure continuity of care for expectant mothers who begin prenatal care in one location and move for employment purposes during their pregnancy. Bilingual, culturally competent staff link migrant patients with prenatal services and manage their medical records throughout the pregnancy.
Fairview Health Services' palliative care program offers palliative care clinical and support services to inpatients, outpatients, and home care patients to mitigate suffering and improve quality of life; the program is integrated into the care process to facilitate referrals and care coordination.