Statewide Medical Home Program for Low-Income Pregnant Women Enhances Access to Comprehensive Prenatal Care and Case Management, Improves Outcomes
A State-based, public–private partnership adapted its successful primary care medical home model to serve pregnant Medicaid beneficiaries, leading to enhanced access to comprehensive prenatal care (including intensive case management for high-risk pregnancies), better adherence to evidence-based care standards, and reductions in low–birth weight babies and rate of primary Cesarean sections.
Care Coordinators Support Individuals With Severe Mental Illness, Leading to Improved Quality of Life and Lower Costs
The seven-county New York Care Coordination Program offers comprehensive care coordination for individuals with severe mental illness through assessment, individualized goal setting, and access to social programs, leading to improved quality of life and coping skills, fewer emergency department visits and inpatient days, and lower costs.
Community Coalition Connects Medical Practices to Community Resources, Leading to Improved Asthma and Diabetes Outcomes in At-Risk Populations
King County Steps to Health connected medical practices to community resources by encouraging organizations to work together to identify common messages, leverage resources, and develop programs for populations at risk for diabetes, asthma, and obesity.
Community Partners Offer Financial Incentives and Support for Primary Care Practices, Improving Access and Reducing Utilization for Children on Medicaid
The Children's Healthcare Access Program offers financial incentives and support services to primary care medical homes serving children covered by Medicaid and their families; the program enhanced access to primary care, increased the percentage of children with asthma action plans, reduced emergency department visits and hospital admissions, increased well-child visits, and reduced costs.
Statewide Health Information Exchange Provides Daily Alerts About Emergency Department and Inpatient Visits, Helping Health Plans and Accountable Care Organizations Reduce Utilization and Costs
A statewide health information exchange provides health plans and accountable care organizations with daily alerts on patients visiting the emergency department or being admitted to an inpatient facility, allowing them to take steps to curb use of these high-cost venues and replace them with lower-cost primary care visits.
Clinical–Community Relationships Measures Atlas
AHRQ developed the CCRM Atlas to identify ways to further define, measure, and evaluate programs based on clinical-community relationships for the delivery of clinical preventive services.
Clinical–Community Relationships Evaluation Roadmap
The Clinical–Community Relationships Evaluation Roadmap is intended to serve as a general guide and resource for future research and evaluation into the design and implementation of effective clinical–community resource relationships for the provision of selected clinical preventive services.
Sharing Specialty Services: A Business Guide and Toolkit for Community Clinics
This business planning guide is designed to assist CCHCs and clinic consortia as they consider developing networks to share specialty services.
Establishing a Child Health Improvement Partnership: A How-to Guide
This guide attempts to share the best thinking and knowledge about what existing IPs have been able to accomplish.
Health Information Exchange Toolkits
This Web page from the HIMSS offers three toolkits that provide information about HIE organizations, networks, and initiatives at the local, regional, and State level.