A partnership between a large health system and 512 churches supports the transition from the hospital back into the community, leading to lower mortality, health care utilization, and health care costs and to higher satisfaction with hospital care.
Hospital-based social workers support recently discharged older patients and their caregivers in resolving problems related to their transition back home, leading to enhanced patient and caregiver knowledge, better attendance at followup appointments, and fewer readmissions and deaths.
Through a partnership between the Veterans Administration and the Alzheimer's Association, a two-person care coordinator team provided support to patients with dementia and their caregivers over a 12-month period. The program led to improved psychosocial outcomes for veterans and caregivers, fewer readmissions and institutional placements, enhanced access to outpatient services, and higher overall health care costs.
An emergency medical system provider uses advance practice paramedics to provide in-home and telephone-based support to patients who frequently call 911, reducing the use of ambulance and emergency department services.
A partnership between academic medicine and a major-league sports team enhances access to care by providing treatment and support to veterans who suffer from traumatic brain injury and posttraumatic stress disorder and their families, generating high levels of patient satisfaction.
Public health nurses provide case management services to women with one or more chronic conditions who receive Temporary Assistance for Needy Families, leading to enhanced access to mental health services, fewer depressive symptoms, and improved functional status.
Two safety net clinics offered low-income Hispanic patients with both diabetes and depression culturally appropriate care (including medication and/or psychotherapy) and ongoing support led by trained, bilingual social workers, leading to improvements in medication adherence, depression-related symptoms, and patient satisfaction.
Hospital-based interdisciplinary teams conduct daily reviews of real-time information on all inpatients ages 65 and older to identify and address risk factors that can lead to negative outcomes; the program reduced use of urinary catheters and increased use of physical therapy and social work evaluations.
A culturally tailored smoking cessation program significantly reduces tobacco use among members of an American Indian tribe.
Trained health care providers educate patients who use tobacco about the state's free tobacco cessation phone counseling service (called a “quitline”) and then fax a referral form to quitline staff who proactively follow up with the patient; the program led to higher quit rates than among those simply informed about the quitline by their providers.