Care management processes

Innovations

Primary Care–Based, Multidisciplinary Teams Provide Care Management Services to Complex Patients, Enhancing Patient Engagement and Reducing Hospitalizations 06/27/16

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.

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.

Committee Reviews and Advises on Cases of Alleged Unprofessional Behavior as Alternative to Formal Investigation, Leading to Improvements in Physician Behavior 12/19/14

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 Does Not Improve Blood Pressure or Glycemic Control in Diabetes Patients 11/06/14

Home telemonitoring did not improve blood pressure or blood glucose control in diabetes patients with out-of-range values.

Physician-Led Clinics Offer Integrated, Coordinated Care to High-Risk Seniors Under Capitated Contracts, Leading to Strong Performance on Quality Metrics, Low Inpatient Use, and High Patient Satisfaction 11/04/14

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.  

Regional Commission Made Up of Diverse Stakeholders Enhances Access to Coverage and Services for Low-Income Residents, Reducing Readmissions and Emergency Department Visits 11/04/14

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.

Integration of Behavioral Health Team and Consulting Psychiatrist Into Primary Care Enhances Access to Behavioral Health Care for Low-Income Patients 11/02/14

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 Provide Counseling, Onsite Testing and Vaccinations, and Case Management, Enhancing Access to Hepatitis Assessment and Treatment 10/31/14

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.

Statewide Managed Care Plan for Foster Care Children Features Care Coordination and a Central Database, Leading to Improved Access and Mental Health Treatment 10/31/14

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.

Cross-Division Surgical Group Conducts Quarterly Review as Supplement to Traditional Department-Specific Morbidity and Mortality Reviews, Leading to Lower Mortality Rates 09/18/14

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.

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