A county-based accountable care organization integrates medical, behavioral health, and social services and assigns a care coordinator to newly enrolled Medicaid beneficiaries to promote use of appropriate services, leading to fewer readmissions and emergency department visits and lower costs.
Before seeing their provider, patients with diabetes complete an easy-to-use assessment tool that helps identify and address their biggest quality-of-life concerns, generating overwhelmingly positive feedback from patients and clinicians.
A statewide consortium of community health workers, public agencies, and nonprofits aimed to reduce health disparities by developing a standardized scope of practice, creating a training and certificate program and a stable funding strategy to secure reimbursement from Medicaid. Their work resulted in greater integration for these workers in the health care work force.
A culturally tailored smoking cessation program significantly reduces tobacco use among members of an American Indian tribe.
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.
Hospital case managers telephone skilled nursing facility nurses within 48 hours of each heart failure patient's discharge to verify that appropriate care management is being provided, leading to a significant reduction in readmissions and associated cost savings.
A collaborative medication review process involving physicians, nurses, and pharmacists virtually eliminates medication errors and significantly reduces readmissions in patients discharged to a nursing home.
A dementia care facility takes a person-centered approach to caring for residents who exhibit challenging, aggressive behavior, leading to less need for psychiatric hospitalizations and behavior-related medications.
CIGNA uses a multifaceted approach to facilitate culturally appropriate behavioral health care for members, including the matching of patients to providers who meet desired characteristics; the program enhanced the diversity of the behavioral health practitioner network and increased member satisfaction.
A statewide smoking cessation program tailored to the lesbian, gay, bisexual, and transgender community enhances access to culturally tailored services, increases knowledge and understanding among tobacco cessation coaches, and generates high levels of satisfaction among participants.