Coordination of care

Innovations

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...

Regional Commission Made Up of Diverse Stakeholders Enhances Access to Coverage and Services for Low-Income Residents, Reducing Readmissions and Emergency Department Visits 11/04/14

The St. Louis Regional Health Commission is a diverse consortium of collaborating stakeholders (providers, civic leaders, community activists, and local and State government officials) that...

Methadone Treatment Centers Provide Counseling, Onsite Testing and Vaccinations, and Case Management, Enhancing Access to Hepatitis Assessment and Treatment 10/31/14

As part of a clinical trial, methadone maintenance treatment centers in New York and San Francisco provided drug users with education and counseling based on principles of motivational...

Statewide Managed Care Plan for Foster Care Children Features Care Coordination and a Central Database, Leading to Improved Access and Mental Health Treatment 10/31/14

The Texas STAR (State of Texas Access Reform) Health Program is a statewide managed care plan for children and young adults in foster care and young adults who have aged out of the foster care...

Emergency Department–Based Asthma Clinic Improves Self-Management Behaviors and Reduces Acute Episodes for Low-Income, Inner-City Children and Teenagers 09/17/14

Through a program known as IMPACT DC (Improving Pediatric Asthma Care in the District of Columbia), Children's National Health System has an emergency department–based clinic that serves low-...

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...

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...

Transitioning Newborns From NICU to Home: A Resource Toolkit 01/24/14

This toolkit for hospitals provides information and resources to improve safety when newborns transition home from the neonatal intensive care unit (NICU). Through a Health Coach Program, the toolkit offers coaches, parents, and families...

Predictive Modeling: A Guide for State Medicaid Purchasers 01/16/14

This guide for care managers and State Medicaid agencies provides information on how to use predictive modeling tools to identify patients who are good candidates for care management. A list of key considerations can help States prioritize and...

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