Care management processes

Innovations

Primary Care–Based, Multidisciplinary Teams Provide Care Management Services to Complex Patients, Enhancing Patient Engagement and Reducing Hospitalizations 06/27/16

The San Francisco Health Network embeds multidisciplinary teams within primary care practices to provide “wraparound” services to medically and psychosocially complex patients. Made up of nurses,...

Collaborative Health Education and Access Events Offer No-Cost Screenings and Navigation Services To Connect Lesbian, Gay, Bisexual, and Transgender Individuals With Medical Homes Offering Culturally Competent Care 12/19/14

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...

Committee Reviews and Advises on Cases of Alleged Unprofessional Behavior as Alternative to Formal Investigation, Leading to Improvements in Physician Behavior 12/19/14

Each of the three hospitals within the University of Pennsylvania Health System has a Professionalism Committee that can handle cases of alleged disruptive, unprofessional behavior by a physician...

Home Telemonitoring Does Not Improve Blood Pressure or Glycemic Control in Diabetes Patients 11/06/14

Six family medicine and internal medicine clinics affiliated with the University of Missouri provided diabetes patients who had uncontrolled blood pressure, uncontrolled blood glucose, or both...

Physician-Led Clinics Offer Integrated, Coordinated Care to High-Risk Seniors Under Capitated Contracts, Leading to Strong Performance on Quality Metrics, Low Inpatient Use, and High Patient Satisfaction 11/04/14

ChenMed is a physician-led practice serving more than 20,000 Medicare-eligible seniors through 36 centers in six States. ChenMed offers integrated, coordinated care under capitated contracts...

QualityTools

Connecting Those at Risk to Care: The Quick Start Guide to Developing Community Care Coordination Pathways 03/03/16

This quick start guide complements the Pathways Community HUB Manual: A Guide To Identify and Address Risk Factors, Reduce Costs, and Improve Outcomes, published in 2016 by the Agency for Healthcare Research and Quality (AHRQ). That manual...

Patient and Family Engagement Resource Compendium 02/23/16

The Health Research & Educational Trust (HRET) developed this compendium to link patient and family engagement concepts and strategies to available resources. The compendium resources are designed to support hospital efforts to partner with...

Family-Centered Rounds Toolkit 02/12/15

The Family-Centered Rounds Toolkit is designed to encourage, assist, and improve family engagement during family-centered rounds (FCR). Family-centered rounds encourage patient and family learning and involvement in health care decisionmaking....

Mobile Health Roadmap 07/16/14

The Mobile Health Roadmap provides guidance to professionals, organizations, corporations, and health systems on the adoption of mobile and mHealth (mobile health) devices. Mobile devices are becoming increasingly present in the health community...

Safety Net Medical Home Initiative: Resources and Tools 06/16/14

This library of publicly available resources and tools can help safety net providers understand and implement the patient-centered medical home (PCMH) model of care. Users can navigate these free resources by type or topic or by the registry of...

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