Improving patient self-management
A program known as Cash & Counseling gives Medicaid enrollees a monthly allowance for home care and related services that they can spend at their own discretion, leading to enhanced access to services, fewer unmet needs, improved health outcomes, and high levels of beneficiary satisfaction.
A multistakeholder collaborative, the Rochester Blood Pressure Initiative supports the development and implementation of a variety of provider-, employer-, and community-based programs that have collectively improved blood pressure control among hypertensive individuals in metropolitan Rochester, NY.
A health plan supports providers in orthopedic clinics in distributing decision aids to patients and using shared decisionmaking, contributing to reductions in joint replacement surgeries and overall health care costs.
A comprehensive bundle of process improvement strategies improved patient turnaround time in the emergency department, which in turn led to fewer patients leaving before being treated.
Patients with Crohn's disease reported information on nine observations of daily living (cues about health experienced in everyday living) using applications on a tablet computer, leading to more tracking of symptoms and health-related behaviors, better patient self-management and patient-provider communication, and high levels of patient satisfaction.
The Children's Healthcare Access Program offers financial incentives and support services to primary care medical homes serving children covered by Medicaid and their families; the program enhanced access to primary care, increased the percentage of children with asthma action plans, reduced emergency department visits and hospital admissions, increased well-child visits, and reduced costs.
Nurse case managers at a Veterans Affairs hospital provide inhospital and post-discharge, telephone-based support to at-risk, community-dwelling patients and their caregivers, leading to better care transitions, fewer readmissions, and substantial cost savings.
A State-based, public–private partnership adapted its successful primary care medical home model to serve pregnant Medicaid beneficiaries, leading to enhanced access to comprehensive prenatal care (including intensive case management for high-risk pregnancies), better adherence to evidence-based care standards, and reductions in low–birth weight babies and rate of primary Cesarean sections.
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.
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.