Home telemonitoring did not improve blood pressure or blood glucose control in diabetes patients with out-of-range values.
A physician-led practice offers integrated, coordinated care under capitated contracts to high-risk, moderate- and low-income seniors enrolled in Medicare Advantage plans, leading to high levels of adherence to recommended screening services, good blood glucose control among patients with diabetes, below-average use of inpatient services, high patient satisfaction, and improvements in patient access to medications.
Daily automated text messages combined with nurse followup improved self-management behaviors among patients with diabetes, leading to significant improvements in glycemic control, fewer doctor visits, lower costs, and high patient satisfaction.
A mobile clinic provides screening, education, coaching, and health navigation services to residents of four underserved communities, leading to the identification of many previously undetected chronic conditions, better blood pressure control, and a substantial return on investment.
A low-cost, community-based, culturally tailored education program led by a bilingual nurse practitioner helped Korean immigrants with type 2 diabetes improve self-management behaviors and achieve better control of the disease.
A rural medical practice redesigned its care processes to allow multidisciplinary care teams to use a new electronic health record system that features real-time documentation and information sharing and various tools to facilitate the provision of appropriate care, leading to significant improvements in screening rates and high satisfaction for medically underserved patients in Alaska.
Primary care practices use a software-facilitated process to proactively schedule and efficiently complete required components of Medicare's Annual Wellness Visit and to identify and address care gaps, leading to improvements in the provision of preventive services and high physician and patient satisfaction.
A health system allows patients to receive certain routine laboratory tests without a physician's order, enhancing access to these tests and generating positive feedback.
Using electronic templates, nurses and physicians provide a personalized report to patients at virtually every visit, with the goal of improving health-related behaviors; the program has contributed to a leveling off in the prevalence of overweight/obesity, above-average quit rates among smokers, better blood glucose control, and fewer racial disparities in chronic care.
The Full Circle Diabetes program provides comprehensive care and self-management support to Native Americans with diabetes, leading to improvements in health-related behaviors, clinical outcomes, and emotional health.