Training, knowledge management
Protocol-based care management tools and simplified documentation forms embedded in the electronic medical record improve documentation, the readability of notes, and coding accuracy in military health care facilities.
A health plan–sponsored disease management program targeting African Americans combines home blood pressure monitoring with culturally competent education and counseling, leading to better self-monitoring and blood pressure control.
Community outreach workers identify residents at risk of nursing home placement and arrange for them to receive appropriate home- and community-based services, leading to fewer nursing home placements and significant cost savings.
Medical students operate a free primary care health clinic for visitors to a large, local soup kitchen, gaining invaluable experience and providing patients with medical care they would otherwise likely go without.
Intensive, person-centered case management, peer support, and a discretionary fund for adults with serious mental illness leads to better access to treatment, job training, and employment; fewer suicide/self-harm attempts, hospitalizations, incarcerations, and days of homelessness; and lower mental illness-related costs.
Pharmacists provide ongoing chronic care management support to employees and their physicians, leading to greater adherence to recommended care processes and self-management behaviors, lower costs, higher productivity, and a significant return on investment.
Case managers remotely monitor Medicare beneficiaries with chronic conditions via a messaging device that asks and records answers to disease-specific and general health questions each day, leading to lower mortality and costs.
Trained school nurses held four weekly, one-on-one sessions with high school students who smoke; the sessions did not have a larger impact on long-term smoking rates than did four shorter, information-focused sessions, but both types of counseling generated higher long-term quit rates than typical programs targeted at teen smokers.
A nonprofit organization trains and places culturally competent home health workers to provide care for low-income, Asian-American seniors with limited English proficiency, leading to enhanced access to culturally competent care.
The Advanced Illness Management program supports Medicare patients with advanced illness and their families in making patient-centered decisions, leading to greater use of hospice care, lower inpatient and ambulatory utilization and overall care costs, and high levels of patient, family, and physician satisfaction.