Care management processes
Multidisciplinary teams embedded within primary care practices provide care management and other support services to medically and psychosocially complex patients, enhancing patient engagement and self-management skills and reducing hospitalizations and emergency department visits.
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.
Three hospitals within the University of Pennsylvania Health System succeeded in changing physician behavior through a Professionalism Committee that handles cases of alleged disruptive, unprofessional behavior by a physician, as an alternative to a formal investigation under medical staff bylaws.
Home telemonitoring did not improve blood pressure or blood glucose control in diabetes patients with out-of-range values.
A physician-led practice offers integrated, coordinated care under capitated contracts to high-risk, moderate- and low-income seniors enrolled in Medicare Advantage plans, leading to high levels of adherence to recommended screening services, good blood glucose control among patients with diabetes, below-average use of inpatient services, high patient satisfaction, and improvements in patient access to medications.
A regional health commission made up of a diverse group of stakeholders promotes various activities and policies to support the safety-net health system, enhancing access to coverage, medical and dental care, and medical homes, and reducing readmissions and inappropriate use of the emergency department.
Primary care clinics integrate a full-time behavioral health team and part-time consulting psychiatrist into the practice, enhancing access to behavioral health services, helping patients become more engaged in their own care, and increasing primary care clinician involvement in addressing patients' behavioral health issues.
Methadone treatment centers provided drug users with access to screening and care for hepatitis, including education and counseling based on motivational interviewing principles, onsite testing and vaccinations, referrals for additional assessments and treatment, and ongoing case management services, leading to enhanced access to hepatitis vaccinations and clinical evaluations and treatment.
Supported by a central data repository, a statewide managed care plan for children and young adults in foster care provides ongoing care coordination, linkages to community-based services, and psychotropic drug utilization reviews, leading to better care access, better followup after mental illness hospitalization, and less use of psychotropic drugs.
As an adjunct to traditional morbidity and mortality reviews, a teaching hospital convenes representatives from its 11 surgical groups on a quarterly basis to review mortality-related data and discuss trends, problems, and opportunities for systematic improvement, leading to lower mortality rates and better performance on a composite quality measure.