A health plan's individualized, in-home, environmental asthma intervention program targets all pediatric members with confirmed allergies to indoor allergens and symptomatic asthma. During multiple in-home visits, trained asthma counselors provide education, perform an environmental assessment, demonstrate intervention equipment, devise a written care plan, and assess and address psychosocial issues.
As part of the Geriatric Resources for Assessment and Care of Elders (GRACE) program, social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for low-income seniors, leading to significant improvements in health status.
Beacon Hill Village offers a membership program that provides access to or discounts on a wide array of health care and social support services that are designed to allow people 50 years and older to maintain their health status and independence and thus stay in their own homes as they age (rather than moving to an expensive long-term care facility).
A community-based primary care clinic uses nurses to provide culturally competent care coordination to Latino patients with chronic illnesses and disabilities, leading to greater provision of recommended care, lower health care costs, and enhanced self-management capabilities.
A fall prevention program for seniors who receive home care uses a 12-element assessment tool to identify risk factors for falls and then develops specific interventions designed to reduce these risks; ongoing monitoring of medications and periodic reassessments help to support the effort.
Meadowlark Hills, a retirement community, renovated one of its facilities so residents can live together in group households and become more independent. This led to improved residents' health and a sharp decrease in staff turnover.
The El Rio Inner-City Asthma Intervention Program is a comprehensive bilingual, bicultural program that primarily serves low-income, inner-city Latino children with moderate or severe persistent asthma.
Reconciling patient and provider medication lists reduces discrepancies, leading to enhanced medication safety and high levels of patient and provider satisfaction in the outpatient setting.
A health maintenance organization integrated mental and behavioral health care and nutrition services with primary care delivery, leading to a more than 50-percent reduction in mental health–related hospitalizations.
Cambridge Health Alliance enhanced its round-the-clock interpreter services by tracking key indicators that gauge the quality of these services; analyses of these data led to significant improvements in the program's telephone-based services and staff efficiency and the decision to implement depression screening in patients with limited English proficiency.