Primary care practices leverage information technologies to identify patients at risk of undiagnosed hypertension and schedule them for automated office blood pressure measurement, reducing the likelihood of remaining undiagnosed by more than 70 percent.
Daily automated text messages combined with nurse followup improved self-management behaviors among patients with diabetes, leading to significant improvements in glycemic control, fewer doctor visits, lower costs, and high patient satisfaction.
After being briefed by hospitalists, primary care physicians meet or talk by phone with patients who have complex medication regimens at or soon after discharge, leading to a significant reduction in medication discrepancies.
A local foundation developed community-based testing programs and partnerships with medical homes to provide real-time linkages to HIV care to newly diagnosed patients and to support these patients in transitioning to care, nearly doubling the number of patients initiating treatment.
Master's-level social workers operating out of a centralized department support primary care and specialty clinic patients in dealing with psychosocial and environmental issues, leading to high levels of patient/caregiver and practitioner satisfaction, improvements in patients' well-being and self-management skills, and reductions in resource use.
Physicians and social workers provide free, convenient, culturally appropriate medical care, counseling, and support group services to African-American men in African-American Chicago neighborhoods, enhancing access to these services for roughly 3,000 to 3,500 men each year.
A data exchange platform links individual State PMPs, helping authorized prescribers and pharmacists identify patients who appear to be crossing State lines to obtain drugs for potential personal misuse or illegal activity.
School-based health centers provide comprehensive reproductive and sexual health services to inner-city public school students, leading to enhanced access to contraception, prenatal care, and screening and treatment for sexually transmitted diseases.
Primary care physicians order standardized bundles of tests and specialty referrals for common diagnoses, which are then managed by a care coordination team, resulting in expedited patient care and high physician satisfaction.
Series of interactive videoconference sessions provide didactic and interactive instruction in specialty care to primary care clinicians in community-based clinics, boosting their knowledge and confidence in these areas, and enhancing access to specialty care for their low-income, urban patients.