Improving patient self-management
Hypertensive patients monitor and report multiple blood pressure readings each week and those with elevated readings receive pharmacist feedback and support, leading to better blood pressure control.
Case management combined with in-home environmental assessment and remediation of environmental triggers reduce asthma-related hospitalizations, emergency department visits, missed school days, and missed parent work days in diverse, low-income urban children with asthma.
Onsite care coordination and support of seniors in affordable housing community leads to fewer falls, reduced hospital admissions, improved nutritional status, and increased levels of physical activity, promoting seniors' ability to remain in their homes as they age.
Pediatric practices receive training and in-office support designed to enhance their knowledge and comfort related to screening for risk factors for child abuse and neglect, leading to significantly more screening and significantly less maltreatment.
The Full Circle Diabetes program provides comprehensive care and self-management support to Native Americans with diabetes, leading to improvements in health-related behaviors, clinical outcomes, and emotional health.
With support from a Web-based program, pharmacists provide weekly feedback and host monthly group sessions to help individuals adopt healthier behaviors that reduce cardiovascular risk, leading to increased levels of physical activity, weight loss, and lower systolic blood pressure.
Medicaid managed care enrollees with type 2 diabetes receive free access to YMCA facilities and have regular meetings with nurses, dietitians, and personal trainers that focus on diet, exercise, and other aspects of disease self-management, leading to weight loss and improvements in body mass index, cholesterol, and blood glucose control.
Multidisciplinary, clinic-based teams work with obese children and their families to implement a weight control self-management plan tailored to the child's needs, leading to lower or stabilized body mass index, reductions in screen time and intake of sweetened beverages, and increased physical activity and fruit/vegetable consumption.
Weekly text messaging service for teens and young adults enhances access to sexual health information and services and generates positive changes in behavior and knowledge.
A specially designed pill-bottle system supplied visual and auditory reminders to patients, along with telephone reminders after missed doses and progress reports to be shared with providers; the program significantly increased medication adherence in those with uncomplicated hypertension.