Referrals

Innovations

Church-Health System Partnership Facilitates Transitions From Hospital to Home for Urban, Low-Income African Americans, Reducing Mortality, Utilization, and Costs 11/29/11

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 Follow Up With Recently Discharged Older Adults to Resolve Transition Problems, Reducing Readmissions and Deaths 11/11/11

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.

Partnership Supports Patients With Dementia and Their Caregivers Through Care Coordinator Team, Leading to Improved Psychosocial Outcomes 11/11/11

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.

Trained Paramedics Provide Ongoing Support to Frequent 911 Callers, Reducing Use of Ambulance and Emergency Department Services 11/10/11

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.

Coordinated Treatment and Support Enhance Access to Care for Veterans With Post-Traumatic Stress Disorder and Traumatic Brain Injury and Their Families 11/02/11

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 to Low-Income Women With Chronic Conditions, Leading to Improved Mental Health and Functional Status 10/16/11

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.

Social Worker-Led, Culturally Tailored Therapy and Support Improve Treatment Adherence, Depression-Related Symptoms, and Patient Satisfaction in Low-Income Hispanics With Diabetes 09/26/11

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.

Interdisciplinary Teams Perform Daily Reviews of Real-Time Information to Identify and Address Risk Factors in Older Inpatients 09/05/11

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.

Culturally Tailored Cessation Program Significantly Reduces Tobacco Use Among Members of American Indian Tribe 08/29/11

A culturally tailored smoking cessation program significantly reduces tobacco use among members of an American Indian tribe.

Tobacco Cessation "Quitline" Staff Proactively Call Patients Referred by Trained Providers, Leading to Greater Satisfaction With Services and Higher Quit Rates 07/20/11

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.

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