Through a 1-year program combining medical care with behavioral counseling and practical strategies, a multidisciplinary team of professionals meets with families on an ongoing basis to emphasize good health habits and address a spectrum of lifestyle issues related to pediatric obesity and its complications.
Kaiser Permanente Northern California's Family Violence Prevention Program seeks to improve the identification, prevention, and treatment of domestic violence through a coordinated “systems model” approach, which includes a supportive environment that encourages disclosure of domestic violence to providers, routine screening of high-risk patients, referrals to onsite and community mental health services, and linkages to community resources.
With support from a unit-based nurse champion, stroke unit nurses encourage inpatient smokers to quit through bedside counseling, referral to an outpatient counseling program, and followup with the primary care provider.
A chronic care coordination program employs coordinators to provide telephone-based support to recently discharged patients and other high-risk enrollees, leading to fewer hospitalizations and emergency department visits and lower costs.
The Prevention and Access to Care and Treatment project uses specially trained community health workers to deliver culturally competent, home-based support services to help HIV-positive patients in the inner city.
As part of a collaborative with other hospitals, a health system developed multiple strategies to improve the organ donation request and procurement process, leading to a high conversion rate (the percentage of potential donors who become actual donors); collaborative participants as a group experienced a marked rise in conversion rates and donors.
The Pediatric Practice Enhancement Project places parent consultants in primary care practices to help families with special needs children navigate the health care system and access community-based psychosocial and financial services.
The St. John Bosco Clinic provides free, bilingual primary and specialty care, referrals, and patient education to Hispanic immigrants who are generally poor, undocumented, and uninsured.
Teams of providers proactively visit homes, shelters, and the streets to locate frequent emergency department visitors and provide them with preventive care and other social services.
A community health educator referral liaison receives physician referrals of patients with risky health behaviors; the liaison links patients with community resources, offers counseling and encouragement over the telephone, and provides feedback to the physicians.