Care management processes
A state-funded program gives individuals with mental illness a quarterly allowance for mental health and wellness services that can be spent at their own discretion, allowing them to spend more time living in the community and to function more effectively.
Large health care systems in Detroit came together to develop an organizational structure and common goals and policies designed to strengthen the safety net for uninsured residents, leading to increased enrollment in public insurance, enhanced access to primary and specialty care, and lower uncompensated care costs.
A statewide consortium of community health workers, public agencies, and nonprofits aimed to reduce health disparities by developing a standardized scope of practice, creating a training and certificate program and a stable funding strategy to secure reimbursement from Medicaid. Their work resulted in greater integration for these workers in the health care work force.
A statewide, multipayer pilot program provides technical and financial support to physician practices interested in becoming patient-centered medical homes, leading to all participating practices being recognized as medical homes and to anecdotal reports of better access and higher quality.
Specially trained and certified lay workers known as “Grand-Aides” use illness-specific protocols to ensure that patients receive appropriate treatment in primary care settings and to ease the transition from hospital to home after discharge. The primary care-based program has reduced unnecessary visits and demonstrated the potential to reduce costs. Early data from one hospital program show significant reductions in readmissions.
A medical center uses a standard protocol to improve collection of racial, ethnic, and language data from patients, leading to better interpretation services for patients with limited English proficiency and to more consistent, higher quality care for cardiac patients.
As required by law, hospitals in New York track and report information on select hospital-acquired infections to the State Department of Health, which publicly releases hospital-specific performance data and supports hospitals with quality improvement initiatives; the program has reduced infection rates and generated substantial cost savings.
A partnership among a periodontist, hospitals, state-funded health clinics, and area dentists enhances access to comprehensive dental care and education about oral hygiene to thousands of low-income pregnant women.
Kaiser Permanente Colorado and the Visiting Nurse Association in Denver jointly offer intense, consistent education to elderly heart failure patients discharged from the hospital in need of home-based skilled nursing care, leading to improved knowledge and self-management skills and fewer readmissions.
As part of a statewide public-private initiative, the diverse Burlington (Vermont) health service area supports 18 patient-centered medical home practices via a multidisciplinary team, real-time electronic information, and financial incentives, leading to more appropriate care, better health outcomes and patient experiences, and lower utilization and costs.