Patient Population

Innovations

Trained Peers Educate and Support Veterans in Self-Management of Hypertension, Leading to Improved Blood Pressure and Weight Loss 09/17/14

Trained peers educate and support veterans in managing their blood pressure during regularly scheduled monthly meetings at Veterans Service Organization posts.

Inclusive Design Process and Extensive Promotion and Support Generate Widespread Use of Health Information Exchange, Leading to Improvements in Health Outcomes 09/17/14

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.

Technology-Facilitated Education and Consultations With Lactation Specialists Triple Breastfeeding Rates Among Low-Income Minority Women in Primary Care Clinics 05/26/14

Obstetrics/gynecology clinics offered electronic medical record–facilitated education, counseling, and support from a lactation consultant to low-income minority women, leading to a threefold increase in breastfeeding rates.

Information Technology-Facilitated Identification of At-Risk Primary Care Patients Combined With In-Office Automated Measurement Significantly Reduces Undiagnosed Hypertension 05/19/14

Primary care practices leverage information technologies to identify patients at risk of undiagnosed hypertension and schedule them for automated office blood pressure measurement, reducing the likelihood of remaining undiagnosed by more than 70 percent.

Daily Text Messages and Nurse Followup Improve Self-Management Behaviors in Patients with Diabetes, Leading to Better Glycemic Control and Lower Costs 04/28/14

Daily automated text messages combined with nurse followup improved self-management behaviors among patients with diabetes, leading to significant improvements in glycemic control, fewer doctor visits, lower costs, and high patient satisfaction.

Managed Care Entity Funded By Public Agencies Reduces Institutionalization and Recidivism, and Improves School Attendance and Functional Ability Among Emotionally Disturbed Youth 03/30/14

Funded by and receiving referrals from the various public systems serving at-risk youth, Wraparound Milwaukee pays for and supports the provision of coordinated mental health and support services to children and adolescents with serious emotional and mental health needs, leading to less institutionalization and recidivism, lower costs, increased school attendance, better functioning at home and in school, and high satisfaction.

Community-Based Health Coaches and Care Coordinators Reduce Readmissions Using Information Technology To Identify and Support At-Risk Medicare Patients After Discharge 03/23/14

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.

Hospital Gain-Sharing Program Offers Incentives to Physicians Based on Their Efficiency, Producing Significant Cost Savings Without Decline in Quality 03/17/14

A group of 12 New Jersey hospitals offered upside incentives to individual physicians based on their performance on various efficiency metrics, leading to significant cost savings without negatively affecting quality of care.

Primary Care Physician Communication With Patients at or Soon After Discharge Significantly Reduces Medication Discrepancies 03/17/14

After being briefed by hospitalists, primary care physicians meet or talk by phone with patients who have complex medication regimens at or soon after discharge, leading to a significant reduction in medication discrepancies.

Community Health Workers Embedded in Inpatient and Outpatient Clinical Teams Enhance Access to Primary Care and Improve Health Outcomes for Low-Income Patients 03/13/14

Community health workers embedded in clinical teams in medical offices and hospitals support low-income patients in setting and achieving health-related goals and accessing needed medical and community-based services, leading to better communication and access to postdischarge primary care, increased patient activation, fewer readmissions and depression-related symptoms, and positive feedback from patients.

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