Aged adult (80 + years)
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 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 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.
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.
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.
A group of 14 long-term care facilities cede control of immunization policies to a regional pharmacy, leading to a significant increase in influenza vaccination rates among facility workers.
Community health workers known as promotores enhance access to culturally competent mental health education and services, leading to improvements in mental health status and literacy for elderly racial and ethnic minorities.
The State of Minnesota uses financial rewards and penalties to fund nursing home–initiated quality improvement projects through a competitive bidding process, leading to improvements in the quality of care.
Master's-level social workers operating out of a centralized department support primary care and specialty clinic patients in dealing with psychosocial and environmental issues, leading to high levels of patient/caregiver and practitioner satisfaction, improvements in patients' well-being and self-management skills, and reductions in resource use.
As an expansion to an existing community-based oral health program for Hispanic and African-American seniors, dental school faculty, staff, and students offer education and screening for hypertension and diabetes, leading to the identification of many seniors with or at high risk for these chronic illnesses and many previously diagnosed individuals who do not have the condition(s) under control.