Project BOOST (Better Outcomes by Optimizing Safe Transitions) provides hospitals a comprehensive set of interventions to improve the care transition process after discharge, leading to a significant reduction in readmissions.
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.
A safety net hospital employs a software application that uses electronic health record data and predictive modeling to identify and allocate scarce resources to high-risk patients, leading to fewer readmissions and lower costs.
A legislatively authorized, permanent council serves as an effective catalyst for concrete, sustained progress on high-priority policy issues related to end-of-life care in Maryland.
A nonprofit organization in Baltimore provides programs and services to support at-risk women (particularly African Americans) throughout each stage of the childbearing cycle, leading to fewer deliveries of low- and very low–birthweight babies and associated cost savings.
A statewide health information exchange provides health plans and accountable care organizations with daily alerts on patients visiting the emergency department or being admitted to an inpatient facility, allowing them to take steps to curb use of these high-cost venues and replace them with lower-cost primary care visits.
A large health plan offered a 6-month program featuring culturally tailored educational classes and materials and the integration of culturally sensitive approaches into everyday care, leading to increased cultural sensitivity among staff, more engaged patients, and better health outcomes, and contributing (along with other programs) to the elimination of racial disparities.
As an expansion to an existing community-based oral health program for Hispanic and African-American seniors, dental school faculty, staff, and students offer education and screening for hypertension and diabetes, leading to the identification of many seniors with or at high risk for these chronic illnesses and many previously diagnosed individuals who do not have the condition(s) under control.
An online system provides real-time review and eligibility determination for applicants to Oklahoma's Medicaid and the Children's Health Insurance Program, leading to much quicker enrollment, significant cost savings, and a decline in the number of uninsured.
Care coordinators in a large integrated system engage in culturally tailored discussions with low-income seniors about completing advance directives, leading to higher completion rates and a narrowing of the gap in completion rates between African Americans/black immigrants and whites.