Improving patient self-management
A transplant center established a mandatory education session for newly referred patients, leading to a significant increase in the percentage of patients (particularly African Americans and people of lower socioeconomic status) completing the enrollment process.
A statewide program supports physician practices through multidisciplinary community-based health teams, preventive health expertise, easy access to needed information via electronic systems, and financial incentives, leading to lower utilization and growth in health care spending and enhanced provision of appropriate services.
A health system allows patients to receive certain routine laboratory tests without a physician's order, enhancing access to these tests and generating positive feedback.
Primary care doctors offer patients online access to office visit notes, generating high levels of satisfaction and multiple benefits for both patients and physicians.
A health plan–sponsored disease management program targeting African Americans combines home blood pressure monitoring with culturally competent education and counseling, leading to better self-monitoring and blood pressure control.
Community outreach workers identify residents at risk of nursing home placement and arrange for them to receive appropriate home- and community-based services, leading to fewer nursing home placements and significant cost savings.
Intensive, person-centered case management, peer support, and a discretionary fund for adults with serious mental illness leads to better access to treatment, job training, and employment; fewer suicide/self-harm attempts, hospitalizations, incarcerations, and days of homelessness; and lower mental illness-related costs.
Pharmacists provide ongoing chronic care management support to employees and their physicians, leading to greater adherence to recommended care processes and self-management behaviors, lower costs, higher productivity, and a significant return on investment.
Case managers remotely monitor Medicare beneficiaries with chronic conditions via a messaging device that asks and records answers to disease-specific and general health questions each day, leading to lower mortality and costs.
A hospital-based food pantry and cooking classes enhance access to healthful food for low-income families, generating high levels of satisfaction and improvements in diet and health.