King County Steps to Health connected medical practices to community resources by encouraging organizations to work together to identify common messages, leverage resources, and develop programs for populations at risk for diabetes, asthma, and obesity.
To meet the needs of the surrounding community, 11th Street Family Health Services of Drexel University employs a multidisciplinary model of care, offering residents a wide variety of health and wellness services regardless of their ability to pay.
The Michigan Prisoner Reentry Initiative, in partnership with the Muskegon Community Health Project, helps newly released or paroled prisoners access needed health care, contributing to a decline in recidivism.
The Medical Language Interpretive Services program in Grady Health System uses a multipronged approach to increase staffing and the hospital's capacity to provide interpretation services to meet the needs of patients with low English proficiency.
A telephone-based coaching intervention was designed to help hospital-based fall prevention champions identify and implement needed changes in fall-related organizational policies and clinician-specific practices.
As part of the Geriatric Resources for Assessment and Care of Elders (GRACE) program, social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for low-income seniors, leading to significant improvements in health status.
The Hospital Elder Life Program screens all patients aged 70 years and older at admission for the presence of six risk factors for delirium, and then implements targeted interventions to reduce these risks, leading to less cognitive and functional decline and lower costs.
A community-based primary care clinic uses nurses to provide culturally competent care coordination to Latino patients with chronic illnesses and disabilities, leading to greater provision of recommended care, lower health care costs, and enhanced self-management capabilities.
Meadowlark Hills, a retirement community, renovated one of its facilities so residents can live together in group households and become more independent. This led to improved residents' health and a sharp decrease in staff turnover.
Providence Mount St. Vincent (known as “The Mount”) developed and implemented a new model for nursing home care in which most residents live in a “neighborhood” of 20 to 23 residents; neighborhoods contain a cluster of private and semiprivate rooms and a large kitchen/dining area that serves as the central gathering spot for meals and activities. The Mount's approach also focuses on giving residents more independence, autonomy, and dignity than in a traditional nursing home, leading to a greater sense of community and a higher quality of life for residents, as well as a better work environment for employees.