Screening of fifth graders in West Virginia identifies those with a genetic predisposition that can lead to early onset of heart disease and other health risks, with those identified (and their family members) receiving treatment for the condition. The program has screened 100,000 fifth graders and secured treatment for the vast majority of those identified as being at risk.
A large group practice operates an electronic health record system that is closely integrated with a personal health record system that gives patients (and authorized caregivers as proxy users) secure access to key components of their medical records and the ability to request appointments, renew prescriptions, and communicate with physicians electronically. The integrated system has generated high levels of satisfaction among patients and caregivers, who report increased involvement in their health care, and physicians who report being able to practice more efficiently.
An electronic medical record–based system features “soft” and “hard” stop functions designed to ensure that clinicians perform medication reconciliation, leading to a rapid, significant, and sustained increase in adherence rates.
A Web-based service allows adolescents to enter, update, and access critical personal information and to identify key health resources, making them feel more knowledgeable and empowered about their health and enhancing access to high-quality care.
The Santa Clara Family Health Plan encouraged health care practitioners to document body mass index and to provide weight management consultations and referrals to obese adolescents during well visits. While the initiative did not have a major impact on practitioner behavior, it does offer insights into how to develop effective programs to address childhood obesity.
A combination of telephone-based nurse case management and automated symptom monitoring leads to significant reductions in the severity of pain and depression in cancer patients being treated in urban and rural oncology practices.
A primary care physician-health coach team delivers intensive, ongoing care management services to medically complex, chronically ill patients, leading to significant improvements in self-management behaviors, clinical outcomes, and patient satisfaction and to lower utilization and markedly slower growth in costs.
Nurses at Aultman Hospital assess patients preoperatively for risk of pressure ulcers, carefully monitor and address risk factors during surgery, and complete a communication tool to inform postoperative surgical care; the program led to the elimination of Stage 3 and 4 pressure ulcers hospital-wide and very low incidence of Stage 1 and 2 pressure ulcers in surgical patients.
Individuals with asthma receive weekly reports via e-mail that provide detailed information on the use of rescue medications (tracked by a device attached to the rescue inhaler), leading to better asthma control, fewer asthma-related symptoms, enhanced knowledge and awareness, and greater adherence to preventive medication regimens.
Supported by sophisticated information technology and a separate outreach team, cross-trained nurse practitioners run disease-specific clinics in which they educate patients about self-management and proactively manage and coordinate care related to diabetes, wounds, congestive heart failure, hypertension, pulmonary disease, and coronary artery disease; the program has led to significant improvements in outcomes across targeted diseases/conditions.