The seven-county New York Care Coordination Program offers comprehensive care coordination for individuals with severe mental illness through assessment, individualized goal setting, and access to social programs, leading to improved quality of life and coping skills, fewer emergency department visits and inpatient days, and lower costs.
Physicians working in underserved areas use preprinted “prescription pads” to increase use of free community recreational activities and resources by overweight and obese patients, with the goal of helping them achieve a more healthy weight.
The Pathways to a Healthy Bernalillo County Program identifies vulnerable, underserved residents and connects them to needed health and social services.
As part of a quality improvement collaborative, a nonprofit clinic serving uninsured patients created new processes to identify those in need of colorectal cancer screening and smoking cessation education, formed partnerships with community-based organizations and providers to offer additional support to such patients, and participated in ongoing performance monitoring, reporting, and improvement; the program significantly increased the percentage of eligible patients receiving the targeted services.
A care “pathway” helps pregnant substance abusers obtain health insurance, obstetrics care, substance abuse counseling, and other services, allowing the vast majority of these women to give birth to babies with viable birth weight who are free of illicit substances.
Supported by sophisticated information technology and a separate outreach team, cross-trained nurse practitioners run disease-specific clinics in which they educate patients about self-management and proactively manage and coordinate care related to diabetes, wounds, congestive heart failure, hypertension, pulmonary disease, and coronary artery disease; the program has led to significant improvements in outcomes across targeted diseases/conditions.
Health navigators help primary care patients access medical and community resources, leading to significant improvements in health-related and self-management behaviors and health outcomes and to meaningful declines in emergency department and inpatient utilization.
An integrated health plan provider system sends every member due for colorectal cancer screening an in-home fecal immunochemical test kit and conducts various folllowups with those who do not return a completed specimen for processing; the program led to a near doubling of screening rates over a 5-year period.
A three-agency partnership provides a one-stop resource for community-dwelling older adults to learn about and access available resources to help them remain independent, and proactively reaches out to these individuals to assess needs and connect them to services. The program has enhanced access to services and allowed the vast majority of nursing home–eligible individuals to improve or maintain the ability to remain in their home.
A peer-led, community-based recovery center offers a wide array of nonmedical support to help individuals recover from mental health and substance abuse disorders; the program has significantly increased participation in employment/schooling, enhanced the ability to secure permanent housing, and helped to keep the vast majority of those served socially connected, drug- and alcohol-free, and out of the criminal justice system.