Care management processes
The Quality Health Network used an inclusive design process and invested significant time and resources in promoting and supporting use of its health information exchange, which serves patients and providers in seven counties in rural western Colorado.
Children's National Health System has an emergency department–based clinic that serves low-income, minority children and teenagers with asthma.
Trained peers educate and support veterans in managing their blood pressure during regularly scheduled monthly meetings at Veterans Service Organization posts.
A series of interventions to reduce “alarm fatigue” on an inpatient cardiac unit leads to significant declines in the number of alarms with no adverse events attributed to the changes and to increases in nurse and patient satisfaction.
Funded by and receiving referrals from the various public systems serving at-risk youth, Wraparound Milwaukee pays for and supports the provision of coordinated mental health and support services to children and adolescents with serious emotional and mental health needs, leading to less institutionalization and recidivism, lower costs, increased school attendance, better functioning at home and in school, and high satisfaction.
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.
A group of 12 New Jersey hospitals offered upside incentives to individual physicians based on their performance on various efficiency metrics, leading to significant cost savings without negatively affecting quality of care.
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.
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.
The State of Maryland provides financial and technical support to five communities designated through a competitive bidding process as health enterprise zones, leading to an expansion of primary care capacity in these areas.