California

An integrated health plan provider system sends every member due for colorectal cancer screening an in-home fecal immunochemical test kit and conducts various folllowups with those who do not return a completed specimen for processing; the program led to a near doubling of screening rates over a 5-year period.

Pharmacists, pharmacy students or residents, and volunteers conduct clinics at primary care practices that help elderly, low-income patients access appropriate, cost-effective medications.

Individuals in cognitive behavioral therapy receive real-time support between therapy sessions by accessing mobile phone applications that prompt them to assess their mood and allow access to self-directed exercises that encourage cognitive reappraisal and physical relaxation. Users of the program report greater self-awareness and mood awareness, improvements in coping skills and mood patterns, and reductions in negative emotions such as anger, sadness, and anxiety.

Culturally and linguistically appropriate education and emotional support to low-income monolingual Chinese immigrants leads to improved knowledge and better blood glucose control in a pilot test of diabetes patients. Based on the success of this pilot, the program has been expanded to serve those with coronary artery disease and congestive heart failure as well.

A hospital makes a telephone-based recording of discharge instructions available to non–English-speaking and low-literacy patients in their native language, leading to improved comprehension of discharge instructions and high levels of patient/family satisfaction.

Care staff use software-based protocols to screen older clients' medications and collaborate with pharmacists and physicians to reduce the risk of medication errors and adverse effects, leading to more appropriate medication use and fewer cases of duplicative medications.

Language-concordant health coaches team with residents to improve the self-management skills of patients who have limited English proficiency and health literacy, leading to improvements in the management, documentation, treatment, and clinical outcomes of patients with diabetes.

A capitated system proactively identifies, screens, and treats those with or at risk for osteoporosis, leading to a 49 percent decline in hip fractures, more than 350 lives saved each year, and tens of millions of dollars in annual cost savings.

Inpatient capacity management strategies initially developed to accommodate the potential influx of patients during a natural or manmade disaster were adopted for everyday use by a capacity-constrained hospital, leading to earlier-in-the-day discharges, steady length of stay despite rising patient acuity, and a multimillion dollar financial return due to increased throughput, with no negative impact on quality or patient satisfaction.

A resident education clinic implemented a multifaceted medical home for children with complex chronic conditions, leading to a significant reduction in emergency department visits and high levels of patient/family satisfaction.