Medically or socially complex

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,...

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...

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...

Integration of Behavioral Health Team and Consulting Psychiatrist Into Primary Care Enhances Access to Behavioral Health Care for Low-Income Patients 11/02/14

Access Community Health Centers (a federally qualified health center) integrates behavioral health services into its three primary care settings through a full-time behavioral health consultation...

QualityTools

2013 National Healthcare Disparities Report 06/26/14

The purpose of the National Healthcare Disparities Report (NHDR) is to identify the differences or gaps through which some populations receive poor or worse care than others and to track how these gaps are changing over time. This report measures...

IMPaCT™ Model Tool Kit 06/04/14

The IMPaCT ™ model is an evidence-based system for community health worker (CHW) recruitment, training, and care. In the IMPaCT model, CHWs provide tailored support to help high-risk patients achieve individualized health goals. This toolkit is...

Young Child Risk Calculator 03/12/14

The Young Child Risk Calculator shows the percentage of young children in a State who face selected risk factors, multiple risks, and risks combined with economic hardship. These risk factors—household without English speaker, large family, low...

Toolkit for the Follow-Up Care of the Premature Infant 03/12/14

This toolkit for health care professionals provides information and resources to help facilitate the care of premature infants and improve their outcomes. It is designed to aid communication between members of the Neonatal Intensive Care Unit (...

Coordinated-Transitional Care Toolkit 03/26/13

Coordinated-Transitional Care (C-TraC) is a low-resource, telephone-based, protocol-driven program designed to reduce 30-day rehospitalizations and to improve care transitions during the early posthospital period. The goal of this toolkit is to...

This website is certified by Health On the Net Foundation. Click to verify. This site complies with the HONcode standard for trustworthy health information: verify here.