The Community Connections for Refugees with Disabilities program proactively identifies newly arriving refugees with disabilities, and then supports them in accessing culturally competent rehabilitation and community-based social services.
A Sickle Cell Day Hospital provides an alternative to inpatient care for patients with sickle cell anemia, with the goal of managing their pain and keeping them out of the hospital, resulting in lower inpatient lengths of stay and emergency department utilization.
Working in collaboration with geriatricians, a nurse practitioner comanaged the care of frail, elderly patients with any of five chronic conditions, leading to better adherence to recommended care processes.
Physicians and nurses provide in-home routine medical care and assessments to newly arrived refugees, leading to enhanced access to health care and social services and better continuity of care for those with chronic illnesses.
A dedicated team of nurses and clerks provides followup support for patients discharged from the emergency department, leading to better quality care, high satisfaction among patients and primary care providers, and fewer patient walkouts.
Culturally competent community liaisons help members of the Orthodox Jewish, Arab, and Chinese communities access health care and community-based services, leading to a better patient experience.
A partnership between a health plan and psychiatric hospitals focuses on sharing of quarterly data, case reviews, and deployment of specific strategies to improve postdischarge care, leading to significant reductions in readmissions, inpatient days, and costs.
A low-overhead clinic enhances access to a broad array of culturally competent, low-cost conventional and alternative medicine services for underinsured, uninsured, and immigrant populations.
Emergency medical technicians screen rural-dwelling older adults for depression, medication-related problems, and falls. A case manager follows up with at-risk individuals to conduct an in-home assessment and provide needed referrals, leading to enhanced access to medical and social services and high levels of satisfaction.
Regional teams of mental health professionals enhance the ability of primary care clinicians throughout Massachusetts to serve children and adolescents with mental health issues.