Congestive heart failure
A safety net hospital employs a software application that uses electronic health record data and predictive modeling to identify and allocate scarce resources to high-risk patients, leading to fewer readmissions and lower costs.
A partnership between a hospital and retail pharmacy company provides inhospital and postdischarge support to patients at high risk of readmission, leading to fewer readmissions and high levels of patient satisfaction.
The State of Connecticut offers employees, retirees, and dependents significant financial incentives to access appropriate care and engage in their health, leading to high participation rates, more appropriate utilization of health care resources, better medication adherence, and slower growth in costs.
Kaiser Permanente Colorado and the Visiting Nurse Association in Denver jointly offer intense, consistent education to elderly heart failure patients discharged from the hospital in need of home-based skilled nursing care, leading to improved knowledge and self-management skills and fewer readmissions.
A university hospital established an infrastructure based on the principles of an accountable care organization, leading to improved management of chronic disease and reduced hospital admissions and medical expenses.
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.
An emergency medical system provider uses advance practice paramedics to provide in-home and telephone-based support to patients who frequently call 911, reducing the use of ambulance and emergency department services.
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.
Working in collaboration with geriatricians, a nurse practitioner comanaged the care of frail, elderly patients with any of five chronic conditions, leading to better adherence to recommended care processes.
Care coordinators remotely monitor veterans with chronic medical conditions via home telehealth devices, leading to reductions in hospital admissions, bed days, and care costs and to high levels of patient satisfaction.