Patient Population

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,...

Community Paramedic Works Onsite in Homeless Shelter, Significantly Reducing Unnecessary 911 Calls and Connecting Residents to Primary Care 04/27/16

A community paramedic works onsite at Harbor Light Shelter, a homeless shelter, during afternoon and evening hours 4 days a week during periods when an onsite primary care clinic is not open. The...

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...

Specially Trained Paramedics Respond to Nonemergency 911 Calls and Proactively Care for Frequent Callers, Reducing Inappropriate Use of Emergency Services 12/19/14

Developed by Christian Hospital and Northwest HealthCare (a two-hospital system that is part of the BJC HealthCare System), Community Health Access Program is a mobile program that...

Trained Consultants Support Caregivers of Patients With Dementia, Leading to Greater Empowerment, Less Use of Medical Services and Long-Term Care, and Cost Savings 12/08/14

Through the Dementia Care Services Program in North Dakota, trained consultants located throughout the State support individuals who care for people with dementia, offering emotional...

QualityTools

Chartbook on Rural Health Care 12/07/15

The Rural Health Care chartbook is part of a series of tools and documents that support the National Healthcare Quality and Disparities Report (QDR). This chartbook includes a summary of the trends across measures of rural health care from the...

Improving Medication Safety in High Risk Medicare Beneficiaries Toolkit 09/04/15

This toolkit is based on experience gained in the Medication Evaluation and Drug Use Problem Identification to Improve Safety in High Risk Medicare Beneficiaries (MEDIS-MB) study. The toolkit has two goals: to describe the medication therapy...

POWER Program Curriculum 09/17/14

The POWER Program is an innovative project designed to help participating veterans manage high blood pressure and other chronic conditions. This Web site provides training materials for the peer health leaders who are the centerpiece of the...

Go4Life Materials To Share 09/17/14

Go4Life is an exercise and physical activity campaign from the National Institute on Aging. It is designed to help adults 50 and older fit exercise and physical activity into their daily lives. The Go4Life Web site provides materials that health...

Integrating Primary Care Practices and Community-Based Resources To Manage Obesity: A Bridge-Building Toolkit for Rural Primary Care Practices 09/17/14

The Integrating Primary Care Practices and Community-Based Resources To Manage Obesity toolkit was developed to help primary care practices manage obesity. It provides tools and concepts informed by the real-world experience of six practices in...

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