Supported by a central data repository, a statewide managed care plan for children and young adults in foster care provides ongoing care coordination, linkages to community-based services, and psychotropic drug utilization reviews, leading to better care access, better followup after mental illness hospitalization, and less use of psychotropic drugs.
A jointly governed consortium of more than 100 local organizations, the Milwaukee Enrollment Network helps county residents (particularly low-income and uninsured individuals) learn about and enroll in public and private health insurance plans.
Trained peers educate and support veterans in managing their blood pressure during regularly scheduled monthly meetings at Veterans Service Organization posts.
This culturally tailored program educates minority populations with diabetes, hypertension, or overweight/obesity about appropriate management of these conditions.
Children's National Health System has an emergency department–based clinic that serves low-income, minority children and teenagers with asthma.
Obstetrics/gynecology clinics offered electronic medical record–facilitated education, counseling, and support from a lactation consultant to low-income minority women, leading to a threefold increase in breastfeeding rates.
Primary care practices leverage information technologies to identify patients at risk of undiagnosed hypertension and schedule them for automated office blood pressure measurement, reducing the likelihood of remaining undiagnosed by more than 70 percent.
Daily automated text messages combined with nurse followup improved self-management behaviors among patients with diabetes, leading to significant improvements in glycemic control, fewer doctor visits, lower costs, and high patient satisfaction.
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.