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.
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.
A clinic uses a team-based collaborative care model that involves a team asessment, an individualized care plan, followup monitoring, and collaboration with primary care providers to treat patients with dementia and support their caregivers, leading to reductions in emergency department visits, inpatient use, readmissions, and medication problems, and to significant cost savings.
Primary care clinics integrate a full-time behavioral health team and part-time consulting psychiatrist into the practice, enhancing access to behavioral health services, helping patients become more engaged in their own care, and increasing primary care clinician involvement in addressing patients' behavioral health issues.
Methadone treatment centers provided drug users with access to screening and care for hepatitis, including education and counseling based on motivational interviewing principles, onsite testing and vaccinations, referrals for additional assessments and treatment, and ongoing case management services, leading to enhanced access to hepatitis vaccinations and clinical evaluations and treatment.
Supported by a central data repository, a statewide managed care plan for children and young adults in foster care provides ongoing care coordination, linkages to community-based services, and psychotropic drug utilization reviews, leading to better care access, better followup after mental illness hospitalization, and less use of psychotropic drugs.
The MyRx Medication Adherence Program offers culturally and linguistically tailored medication management and health education to seniors with hypertension or diabetes who were living in the community.
A jointly governed consortium of more than 100 local organizations, the Milwaukee Enrollment Network helps county residents (particularly low-income and uninsured individuals) learn about and enroll in public and private health insurance plans.
The Quality Health Network used an inclusive design process and invested significant time and resources in promoting and supporting use of its health information exchange, which serves patients and providers in seven counties in rural western Colorado.
This culturally tailored program educates minority populations with diabetes, hypertension, or overweight/obesity about appropriate management of these conditions.