A patient-centered model of care for controlling hypertension incorporates three elements: education and training on use of an existing Web-based system, home monitoring of blood pressure, and periodic contact from pharmacists to review blood pressure readings and adjust therapy as needed.
PinnacleCare provides individualized care management services that include an initial health assessment, an annual health plan/consultation, round-the-clock access to medical advocates and advisers, facilitated access to top specialists and medical institutions, and management of electronic medical records.
Teams of providers proactively visit homes, shelters, and the streets to locate frequent emergency department visitors and provide them with preventive care and other social services.
A home health program enhances services to congestive heart failure and other chronically ill patients by supplementing at-home visits with ongoing remote monitoring and services.
Commonwealth Care Alliance developed a health plan that provides low-income, dually eligible, elderly enrollees in Massachusetts with a primary care team made up of a physician, nurse practitioner, and geriatric specialist who work out of the enrollee's primary care clinic.
Baystate Medical Center's comprehensive heart failure management program incorporates tools and processes that ensure the provision of all necessary components of care, leading to increased adherence to recommended care and reduced heart failure readmission rates.
A solo family practitioner provides 24-hour-a-day, 7-day-a-week access to care for her patients through liberal use of “virtual” or e-mail visits, telephone calls, same-day appointments, and extended office visits.
The On-Time Pressure Ulcer Prevention and Treatment program uses standardized documentation data elements and actionable clinical reports that are integrated into practice at nursing homes, leading to a significant reduction in pressure ulcer rates.
An array of Web-based, interactive tools and services, including an online, shared health record, empowers health plan enrollees to take greater responsibility for their health and health care.
An enhanced chemotherapy dispensing process prioritizes orders for pharmacy processing based on when patients are expected to be on the unit and ready for their chemotherapy, leading to more timely medication administration.