Improving patient self-management
Community health workers provided culturally tailored workshops and one-on-one counseling and support to Filipino Americans at high risk of cardiovascular disease, leading to greater adherence to medication regimens, better attendance at scheduled appointments, improved blood pressure control, and lower body mass index.
Patients receive a notepad with sample questions and informational prompts intended to facilitate communication with physicians, leading to more notetaking by patients and a greater likelihood of having their questions answered by physicians.
The Dentists' Partnership offers free oral health care to low-income individuals in exchange for community service, resulting in a 70-percent decline in emergency department visits for urgent dental conditions, a positive return on investment, and high levels of dentist and patient satisfaction.
The Georgia Medicaid program expanded the definition of reimbursable services provided by mental health peer specialists to include physical health and wellness services, resulting in the training and certification of 175 such specialists to provide these services and in anecdotal reports of improved physical health outcomes among clients who receive the services.
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.
Certified peer specialists provide emotional support, education, links to community services, and other support to individuals with co-occurring medical and mental health diagnoses at two Michigan federally qualified health centers, generating high levels of satisfaction and anecdotal reports of improvements in physical and mental health.
A public–private urban health partnership develops multiple initiatives to expand access to high-quality, coordinated health care for vulnerable residents, leading to shorter wait times for appointments, improvements in patient–provider continuity, and reductions in readmissions and emergency department use.
A primary care medical home for patients with disabilities and complex, chronic medical conditions emphasizes patient engagement and care coordination among medical specialties and social service providers, leading to enhanced access to care, better self-management skills, more days of good health, fewer hospitalizations, and lower costs.
Master's-level social workers operating out of a centralized department support primary care and specialty clinic patients in dealing with psychosocial and environmental issues, leading to high levels of patient/caregiver and practitioner satisfaction, improvements in patients' well-being and self-management skills, and reductions in resource use.
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.