Activities of daily living
Supported by mobile technology, trained health coaches and nurse care coordinators use home visits and telephone-based monitoring to identify and address declines in health status in recently discharged Medicare patients, leading to a significant reduction in readmissions and associated cost savings.
A combined State-Federal program pays health plans a capitated fee to provide and coordinate acute, primary, long-term care as well as social services to those eligible for Medicare and Medicaid, leading to enhanced access to care, fewer inpatient admissions and nursing home placements, and high levels of beneficiary and provider satisfaction.
Patients with Crohn's disease reported information on nine observations of daily living (cues about health experienced in everyday living) using applications on a tablet computer, leading to more tracking of symptoms and health-related behaviors, better patient self-management and patient-provider communication, and high levels of patient satisfaction.
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 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.
Onsite care coordination and support of seniors in affordable housing community leads to fewer falls, reduced hospital admissions, improved nutritional status, and increased levels of physical activity, promoting seniors' ability to remain in their homes as they age.
A Native American tribe–owned skilled nursing facility provides culturally competent services using a holistic approach to health and well-being, leading to high patient and family member satisfaction and low staff turnover.
The Community Connections for Refugees with Disabilities program proactively identifies newly arriving refugees with disabilities, and then supports them in accessing culturally competent rehabilitation and community-based social services.
A tailored, home-based physical therapy program slows functional decline in moderately frail, community-dwelling older adults.
A senior center–based practitioner meets with functionally independent, community-dwelling seniors to assess risk factors and develop a targeted self-management plan, and conducts followup visits and telephone calls with the seniors over a 6-month period to help them adhere to the plan. The program has led to fewer disability days and risk factors for disability, improved self-reported health status and ability to perform activities of daily living, and reduced inpatient utilization.