Care management processes
A legislatively authorized, permanent council serves as an effective catalyst for concrete, sustained progress on high-priority policy issues related to end-of-life care in Maryland.
A nonprofit organization in Baltimore provides programs and services to support at-risk women (particularly African Americans) throughout each stage of the childbearing cycle, leading to fewer deliveries of low- and very low–birthweight babies and associated cost savings.
A statewide health information exchange provides health plans and accountable care organizations with daily alerts on patients visiting the emergency department or being admitted to an inpatient facility, allowing them to take steps to curb use of these high-cost venues and replace them with lower-cost primary care visits.
Care coordinators in a large integrated system engage in culturally tailored discussions with low-income seniors about completing advance directives, leading to higher completion rates and a narrowing of the gap in completion rates between African Americans/black immigrants and whites.
A multifaceted program featuring education and feedback, ultraviolet room disinfection devices, and a dedicated housekeeping team significantly improved the thoroughness of room cleanings and reduced the percentage of rooms housing patients with Clostridium difficile infections that tested positive for the pathogen at patient discharge.
Emergency department clinicians and staff identify veterans at moderate risk of suicide, work with them to develop a safety plan, and follow up after discharge to ensure adherence to the plan and connections to community-based support, leading to better access to outpatient mental health services.
A children's hospital uses an enterprise data warehouse to assist multidisciplinary teams in identifying and addressing opportunities to improve quality, leading to better adherence to evidence-based guidelines, less unnecessary care, and significant cost savings.
A low-cost, community-based, culturally tailored education program led by a bilingual nurse practitioner helped Korean immigrants with type 2 diabetes improve self-management behaviors and achieve better control of the disease.
The Oregon Health Authority (which oversees the State Medicaid program) initiated a series of policy changes to promote earlier detection, more effective referrals, and better coordination of care for pediatric patients with developmental delays, leading to a significant increase in screening rates and enhanced access to early intervention services.
Psychiatric fellows and residents at the University of Virginia Health System in Charlottesville provide care via videoconferencing to patients in rural parts of the state who otherwise would likely not have had access to such care.