Multidisciplinary teams embedded within primary care practices provide care management and other support services to medically and psychosocially complex patients, enhancing patient engagement and self-management skills and reducing hospitalizations and emergency department visits.
A community paramedic works onsite at a homeless shelter during afternoon and evening hours 4 days a week during periods when an onsite primary care clinic is not open, significantly reducing unnecessary 911 calls and connecting shelter residents to primary care.
Lesbian Health Initiative of Houston, Inc., creates a gateway to medical homes for lesbian, gay, bisexual, and transgender women and transgender men through a program that combines culturally competent outreach, education, screening, and patient navigation.
Community Health Access Program helps patients who call 911with nonemergent needs. The dispatcher sends a specially trained paramedic, known as an advanced practice paramedic, to the scene along with the ambulance to confirm that the patient does not need emergency care and then either provide treatment, schedule an appointment with a primary care provider, or arrange for same-day transport to a health resource center.
Trained consultants throughout North Dakota provide emotional support, education, and referrals to support services for those who care for people with dementia, leading to a greater sense of empowerment among caregivers, significantly less need for medical services and long-term care placements among dementia patients, and substantial cost savings.
Home telemonitoring did not improve blood pressure or blood glucose control in diabetes patients with out-of-range values.
An electronic system allows physicians at two health clinics to easily refer patients who use tobacco to a quitline and subsequently monitor their progress, leading to more clinician referrals to the quitline and enhanced access to cessation services for patients.
A health system–community partnership offers resident-initiated programs that expand access to insurance coverage, outpatient care, health education, social support, healthy foods, and opportunities for physical activity for inner-city, low-income minorities.
A culturally tailored support group helps African-American women who are victims of intimate partner violence build coping skills, leading to reductions in depressive symptoms, levels of general distress, suicidal ideation, and suicide attempts.
A regional health commission made up of a diverse group of stakeholders promotes various activities and policies to support the safety-net health system, enhancing access to coverage, medical and dental care, and medical homes, and reducing readmissions and inappropriate use of the emergency department.