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.
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.
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.
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.
Massachusetts banned ambulance diversions and helped hospitals respond to the ban by improving patient flow, leading to reductions in emergency department length of stay for admitted patients, shorter turnaround times for ambulances, and strong support from emergency department leaders who believe the ban has yielded multiple benefits.
With support from State funding, a community mental health center provides integrated mental health, primary care, care coordination, and wellness services to Medicaid beneficiaries with severe and persistent mental illness, leading to better chronic disease outcomes.
Project BOOST (Better Outcomes by Optimizing Safe Transitions) provides hospitals a comprehensive set of interventions to improve the care transition process after discharge, leading to a significant reduction in readmissions.
A safety net hospital employs a software application that uses electronic health record data and predictive modeling to identify and allocate scarce resources to high-risk patients, leading to fewer readmissions and lower costs.
A city health department encourages public and private maternity hospitals to voluntarily adopt various policies to support new mothers who choose to breastfeed exclusively. The program has attracted many participating hospitals, won broad support within the medical community, and increased the proportion of new mothers who breastfeed exclusively during their hospital stay.
A partnership between a hospital and retail pharmacy company provides inhospital and postdischarge support to patients at high risk of readmission, leading to fewer readmissions and high levels of patient satisfaction.