Care management processes
With support from a statewide collaborative, primary care practices in Wisconsin proactively identify and address behavioral health issues in patients, leading to declines in binge drinking, marijuana use, and symptoms of depression, and to high levels of patient satisfaction.
A rural medical practice redesigned its care processes to allow multidisciplinary care teams to use a new electronic health record system that features real-time documentation and information sharing and various tools to facilitate the provision of appropriate care, leading to significant improvements in screening rates and high satisfaction for medically underserved patients in Alaska.
Nurse case managers at a Veterans Affairs hospital provide inhospital and post-discharge, telephone-based support to at-risk, community-dwelling patients and their caregivers, leading to better care transitions, fewer readmissions, and substantial cost savings.
A behavioral health clinic maintains an onsite primary care clinic that provides culturally competent care to low-income Asian Americans with serious mental illness, enhancing access to such care and facilitating modest improvements in physical health.
A hospice offered a dedicated care team trained in culture-specific end-of-life concerns to Hispanic patients and families, and conducted targeted marketing and outreach to Hispanics in the community, leading to greater awareness and acceptance of hospice services.
A State-based, public–private partnership supports quality improvement in pediatric practices, leading to greater adherence to evidence-based care and improved care coordination for children and adolescents, and to higher staff satisfaction in participating practices, and highly rated quality of care for children.
A comprehensive, multi-stakeholder program combines training and higher reimbursement for dental providers with outreach, education, and support to families, leading to enhanced access to dental care, less tooth decay, and lower dental care costs for young, low-income children.
Trained emergency medical technicians use a checklist to identify intoxicated individuals who can safely be transported directly to a local detoxification facility, thus avoiding expensive visits to crowded, resource-constrained emergency departments.
As an alternative to inpatient care, an outpatient center located within a hospital with a stroke center evaluates stable patients who have experienced a recent transient ischemic attack, leading to more timely and comprehensive care, and to significant cost savings through the avoidance of unnecessary admissions.
A State-based, public–private partnership adapted its successful primary care medical home model to serve pregnant Medicaid beneficiaries, leading to enhanced access to comprehensive prenatal care (including intensive case management for high-risk pregnancies), better adherence to evidence-based care standards, and reductions in low–birth weight babies and rate of primary Cesarean sections.