A county-based accountable care organization integrates medical, behavioral health, and social services and assigns a care coordinator to newly enrolled Medicaid beneficiaries to promote use of appropriate services, leading to fewer readmissions and emergency department visits and lower costs.
An HIV clinic proactively encourages men with HIV to be screened for anal cancer each year and makes it easy for them to do so, leading to enhanced access to screening and the identification and removal of precancerous lesions.
A data exchange platform links individual State PMPs, helping authorized prescribers and pharmacists identify patients who appear to be crossing State lines to obtain drugs for potential personal misuse or illegal activity.
The health department in New York City uses subsidies, upfront and ongoing technical support, and quality of care feedback to promote implementation and use of electronic health records by primary care practices in medically underserved areas, leading to better care for patients in these practices.
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.
The Children's Healthcare Access Program offers financial incentives and support services to primary care medical homes serving children covered by Medicaid and their families; the program enhanced access to primary care, increased the percentage of children with asthma action plans, reduced emergency department visits and hospital admissions, increased well-child visits, and reduced costs.
With support from a statewide collaborative, primary care practices in Wisconsin proactively identify and address behavioral health issues in patients, leading to declines in binge drinking, marijuana use, and symptoms of depression, and to high levels of patient satisfaction.
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.
Nurse case managers at a Veterans Affairs hospital provide inhospital and post-discharge, telephone-based support to at-risk, community-dwelling patients and their caregivers, leading to better care transitions, fewer readmissions, and substantial cost savings.
A behavioral health clinic maintains an onsite primary care clinic that provides culturally competent care to low-income Asian Americans with serious mental illness, enhancing access to such care and facilitating modest improvements in physical health.