Referrals

Innovations

Barber-Based Monitoring, Education, and Referral Support Improve Treatment Rates and Blood Pressure Control in African-American Men 12/06/10

Trained barbers provide ongoing blood pressure monitoring, education, and referral support to African-American male patrons, leading to improved treatment rates and blood pressure control in hypertensive patrons.

Proactive Office Encounter Systematically Identifies and Addresses Preventive and Chronic Care Needs at Every Primary Care and Specialty Visit 11/30/10

Nurses and medical assistants use electronic tools and standardized workflows and processes before, during, and after the patient encounter to identify and address preventive, screening, and chronic care needs at every primary and specialty care visit, leading to greater adherence to recommended care processes and better blood pressure control in those with diabetes and hypertension.

Breast Examination Center Assists Low-Income, Minority Women in Accessing Colorectal Cancer Screening 11/29/10

An inner-city breast examination center serving low-income, minority women educates patients about colorectal cancer screening and assists them in getting a colonoscopy screening test, leading to enhanced interest in and access to such screening.

Telephone-Based Coaching on Shared Decisionmaking, Behavioral Change, and Health System Navigation Reduces Utilization and Cost 10/27/10

Health coaches work with at-risk individuals over the phone to develop skills and plans to participate effectively in shared clinical decisionmaking with physicians, self-manage their conditions, and navigate the health system, leading to reduced hospital admissions and medical costs when offered to a larger portion of the population.

Physician "Prescriptions" Written During Medical Visit and "Filled" by Onsite Volunteers Connect Low-Income Families to Vital Community Resources 10/21/10

Physicians in inner-city care settings identify the resource needs of low-income families and write “prescriptions” that these families take to a help desk where college student volunteers connect them to needed resources. The program has successfully connected most clients to these resources, leading to high levels of satisfaction and improved health and well-being.

Statewide Screening of Fifth Graders Leads to Identification and Treatment of Those With Genetic Predisposition to Early-Onset Heart Disease 10/19/10

Screening of fifth graders in West Virginia identifies those with a genetic predisposition that can lead to early onset of heart disease and other health risks, with those identified (and their family members) receiving treatment for the condition. The program has screened 100,000 fifth graders and secured treatment for the vast majority of those identified as being at risk.

Hospital Partnership Offers Pathways-Based Case Management Program, Leading to Enhanced Access to Appropriate Care for Uninsured 10/19/10

A joint case management program sponsored by two competing hospitals addresses the health and social needs of uninsured and underinsured individuals who have a history of using the emergency department for nonemergent issues. The program has led to enhanced access to appropriate care and to a significant decline in emergency department use and costs for nonemergent conditions.

Provider Training on Adolescent Weight Management Promotes Body Mass Index Documentation and Referrals to Health/Fitness Classes, But at Rates Below Health System Goals 09/22/10

The Santa Clara Family Health Plan encouraged health care practitioners to document body mass index and to provide weight management consultations and referrals to obese adolescents during well visits. While the initiative did not have a major impact on practitioner behavior, it does offer insights into how to develop effective programs to address childhood obesity.

Telephone-Based Care Management With Automated Symptom Monitoring Reduces Pain and Depression in Cancer Patients 09/14/10

A combination of telephone-based nurse case management and automated symptom monitoring leads to significant reductions in the severity of pain and depression in cancer patients being treated in urban and rural oncology practices.

Community Partnership Uses Lay Health Advisers to Reduce Chronic Disease Risk Factors, Leading to Improvements in Lifestyle and Health in Low-Income African Americans 08/15/10

A primary care center, county health department, community organizations, and lay health advisers jointly developed and implemented various activities to reduce risk factors for cardiovascular disease and diabetes in a low-income, largely African-American population, leading to improvements in health-related behaviors and better health.

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