Improving patient self-management
Virginia Mason Medical Center created a spine clinic that provides rapid, efficient treatment for uncomplicated low back pain, with the goal of allowing patients to return to their jobs and other regular activities as soon as possible.
Home telemonitoring did not improve blood pressure or blood glucose control in diabetes patients with out-of-range values.
A health system–community partnership offers resident-initiated programs that expand access to insurance coverage, outpatient care, health education, social support, healthy foods, and opportunities for physical activity for inner-city, low-income minorities.
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.
Trained peers educate and support veterans in managing their blood pressure during regularly scheduled monthly meetings at Veterans Service Organization posts.
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.
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.