A collaborative program leverages information technology to connect ED patients to a medical home and patients receiving care at FQHCs and county health clinics to specialists, leading to enhanced access to care, fewer ED visits, and significant cost savings.
Emergency department–based case managers at nine Milwaukee hospitals use electronic technologies to schedule and track attendance at follow-up clinic appointments for low-income, uninsured patients who come to the emergency department with nonurgent needs, allowing many such patients to establish a medical home.
A multidisciplinary hospital team reaches out to and meets with patients and family members in a compassionate, supportive manner, allowing them to better deal with the loss of a loved one or other unexpected, negative events.
Community outreach workers identify residents at risk of nursing home placement and arrange for them to receive appropriate home- and community-based services, leading to fewer nursing home placements and significant cost savings.
Medical students operate a free primary care health clinic for visitors to a large, local soup kitchen, gaining invaluable experience and providing patients with medical care they would otherwise likely go without.
Intensive, person-centered case management, peer support, and a discretionary fund for adults with serious mental illness leads to better access to treatment, job training, and employment; fewer suicide/self-harm attempts, hospitalizations, incarcerations, and days of homelessness; and lower mental illness-related costs.
Primary care physicians order standardized bundles of tests and specialty referrals for common diagnoses, which are then managed by a care coordination team, resulting in expedited patient care and high physician satisfaction.
A hospital-based food pantry and cooking classes enhance access to healthful food for low-income families, generating high levels of satisfaction and improvements in diet and health.
A nonprofit organization trains and places culturally competent home health workers to provide care for low-income, Asian-American seniors with limited English proficiency, leading to enhanced access to culturally competent care.
Series of interactive videoconference sessions provide didactic and interactive instruction in specialty care to primary care clinicians in community-based clinics, boosting their knowledge and confidence in these areas, and enhancing access to specialty care for their low-income, urban patients.