Care management processes
A traveling team of certified diabetes educators (including a nurse, pharmacist, and dietitian) regularly visits rural clinics to help coordinate diabetes care with clinicians and educate and coach African-American patients with diabetes, leading to improved glycemic control and the potential for meaningful cost savings.
An Arizona clinic for women refugees provides comprehensive, culturally sensitive care across the reproductive life span, leading to enhanced access to services, high patient satisfaction, greater awareness of breast cancer and mammography, and better planning for childbirth.
A community-based oncology practice's patient-centered medical home model features oncology-specific information technology, a standardized assessment, multidisciplinary care plan, patient navigators, telephone triage line, patient education and engagement, and ongoing performance monitoring, leading to improvements in access, quality, and costs.
A children's hospital requires providers to look at a patient's picture and basic demographic information on a verification screen when entering and signing an order, leading to significant reductions in patients receiving or almost receiving care intended for someone else because of an order being placed in the wrong chart.
An alliance of government and not-for-profit agencies aided the passage of various legislative provisions in Massachusetts designed to create a more stable, systemic role for community health workers, leading to greater professional recognition, an expanded workforce and training infrastructure, and increased funding of services.
Patients track preventive health needs, complete health risk assessments, and obtain educational information through an online interactive health record integrated with their practice's electronic health record, leading to improvements in the provision of preventive care.
Primary care practices use a software-facilitated process to proactively schedule and efficiently complete required components of Medicare's Annual Wellness Visit and to identify and address care gaps, leading to improvements in the provision of preventive services and high physician and patient satisfaction.
In a partnership between a hospital and four community-based organizations, bilingual community health workers help low-income, predominantly Latino families with asthmatic children better manage the disease, leading to fewer asthma-related symptoms, hospitalizations, emergency department visits, and missed school days.
A dedicated inpatient unit features a physical environment, staffing, policies, and services tailored to women with severe perinatal depression, leading to improvements in outcomes and high levels of patient satisfaction.
Regulations from the New York State Office of Alcoholism and Substance Abuse Services mandated that all substance abuse treatment facilities in the state become tobacco free and integrate smoking cessation education and therapy into the treatment of other addictions. The regulation resulted in increased access to cessation services and reduced smoking rates among patients and staff as well as some cost savings.