A rural medical practice redesigned its care processes to allow multidisciplinary care teams to use a new electronic health record system that features real-time documentation and information sharing and various tools to facilitate the provision of appropriate care, leading to significant improvements in screening rates and high satisfaction for medically underserved patients in Alaska.
Nurse case managers at a Veterans Affairs hospital provide inhospital and post-discharge, telephone-based support to at-risk, community-dwelling patients and their caregivers, leading to better care transitions, fewer readmissions, and substantial cost savings.
A behavioral health clinic maintains an onsite primary care clinic that provides culturally competent care to low-income Asian Americans with serious mental illness, enhancing access to such care and facilitating modest improvements in physical health.
A hospice offered a dedicated care team trained in culture-specific end-of-life concerns to Hispanic patients and families, and conducted targeted marketing and outreach to Hispanics in the community, leading to greater awareness and acceptance of hospice services.
As part of a comprehensive initiative, State legislation enables trained primary care medical providers to receive Medicaid reimbursement for preventive dental care provided during well-child visits, enhancing access to these services for low-income children younger than 6 years.
A comprehensive, multi-stakeholder program combines training and higher reimbursement for dental providers with outreach, education, and support to families, leading to enhanced access to dental care, less tooth decay, and lower dental care costs for young, low-income children.
As an alternative to inpatient care, an outpatient center located within a hospital with a stroke center evaluates stable patients who have experienced a recent transient ischemic attack, leading to more timely and comprehensive care, and to significant cost savings through the avoidance of unnecessary admissions.
A State-based, public–private partnership adapted its successful primary care medical home model to serve pregnant Medicaid beneficiaries, leading to enhanced access to comprehensive prenatal care (including intensive case management for high-risk pregnancies), better adherence to evidence-based care standards, and reductions in low–birth weight babies and rate of primary Cesarean sections.
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.
A traveling team of certified diabetes educators (including a nurse, pharmacist, and dietitian) regularly visits rural clinics to help coordinate diabetes care with clinicians and educate and coach African-American patients with diabetes, leading to improved glycemic control and the potential for meaningful cost savings.