Nurses and medical assistants use electronic tools and standardized workflows and processes before, during, and after the patient encounter to identify and address preventive, screening, and chronic care needs at every primary and specialty care visit, leading to greater adherence to recommended care processes and better blood pressure control in those with diabetes and hypertension.
A transitional care program that identifies frail elderly patients in the hospital and provides them with in-home support after discharge significantly reduces readmissions and emergency department visits.
A licensed pharmacist or registered nurse periodically consults via telephone over a 7-month period with adult patients with rheumatoid arthritis, leading to improvements in medication adherence and physical functioning and to high levels of patient satisfaction.
A large group practice operates an electronic health record system that is closely integrated with a personal health record system that gives patients (and authorized caregivers as proxy users) secure access to key components of their medical records and the ability to request appointments, renew prescriptions, and communicate with physicians electronically. The integrated system has generated high levels of satisfaction among patients and caregivers, who report increased involvement in their health care, and physicians who report being able to practice more efficiently.
A Web-based service allows adolescents to enter, update, and access critical personal information and to identify key health resources, making them feel more knowledgeable and empowered about their health and enhancing access to high-quality care.
The Santa Clara Family Health Plan encouraged health care practitioners to document body mass index and to provide weight management consultations and referrals to obese adolescents during well visits. While the initiative did not have a major impact on practitioner behavior, it does offer insights into how to develop effective programs to address childhood obesity.
Physicians working in underserved areas use preprinted “prescription pads” to increase use of free community recreational activities and resources by overweight and obese patients, with the goal of helping them achieve a more healthy weight.
Sharp HealthCare incorporates a number of mechanisms to encourage employee engagement in patient service improvements, leading to higher patient satisfaction, perception of higher quality in the community,
Supported by sophisticated information technology and a separate outreach team, cross-trained nurse practitioners run disease-specific clinics in which they educate patients about self-management and proactively manage and coordinate care related to diabetes, wounds, congestive heart failure, hypertension, pulmonary disease, and coronary artery disease; the program has led to significant improvements in outcomes across targeted diseases/conditions.
A Medicare Advantage plan uses employed “extensivists” who perform traditional hospitalist functions for a smaller-than-average caseload of patients, and then continue to follow and care for these patients after discharge until their condition becomes stabilized, leading to low length of stay and fewer readmissions.