Improving patient self-management
The Advanced Illness Management program supports Medicare patients with advanced illness and their families in making patient-centered decisions, leading to greater use of hospice care, lower inpatient and ambulatory utilization and overall care costs, and high levels of patient, family, and physician satisfaction.
A mobile pediatric asthma clinic combined with home visits generated small, short-term increases in symptom-free days in preschool children, and no improvements in other key outcomes.
Small-group discussions and automated, interactive phone calls over a 12-week period helped low-income parents promote healthier behaviors in their overweight children, leading to reductions in body mass index and improvements in health-related quality of life.
Hospital-based social workers support recently discharged older patients and their caregivers in resolving problems related to their transition back home, leading to enhanced patient and caregiver knowledge, better attendance at followup appointments, and fewer readmissions and deaths.
Through a partnership between the Veterans Administration and the Alzheimer's Association, a two-person care coordinator team provided support to patients with dementia and their caregivers over a 12-month period. The program led to improved psychosocial outcomes for veterans and caregivers, fewer readmissions and institutional placements, enhanced access to outpatient services, and higher overall health care costs.
An emergency medical system provider uses advance practice paramedics to provide in-home and telephone-based support to patients who frequently call 911, reducing the use of ambulance and emergency department services.
A portable clinic uses specially designed equipment to bring full-service dental care to elementary schools serving impoverished, immigrant, and uninsured children.
Low-income, African-American, rural HIV patients receive regular self-written text message reminders that encourage them to regularly access HIV/AIDS primary care, leading to greater retention in care and enhanced quality of life.
An integrated health system offered a customized suite of interactive, Web-based education and tools to individuals with diabetes, leading to high levels of engagement, enhanced knowledge and attitudes about the disease, and improvements in hemoglobin A1c levels.
A large employer offers a comprehensive wellness program combined with financial incentives to use its various components, leading to broad participation, improvements in health-related behaviors and risk factors, and a leveling off of overall health care costs.