Chronic Care and Disease Management Improves Health, Reduces Costs for Patients With Multiple Chronic Conditions in an Integrated Health System
The Sutter Care Coordination Program combines chronic care and disease management to address the medical and psychosocial needs of individuals with multiple chronic conditions.
Palliative Care Nurses in Primary Care Clinics Reduce Hospital Admissions, Increase Use of Hospice and Home Care for Patients Nearing End of Life
A partnership between a hospice organization and an 11-location multispecialty group practice places palliative care nurses in primary care clinics to monitor dying patients' medical and social care needs, coordinate community services, and discuss end-of-life issues.
Co-Locating Gynecologic Services Within an HIV Clinic Increases Cervical Cancer Screening Rates, Leading to Identification and Treatment of Many Cancer Cases
By "nesting" a weekly gynecologic clinic into their HIV program, Christiana Care reduces barriers to screening and preventive care for female patients.
Cooperative Network Improves Patient Transitions Between Hospitals and Skilled Nursing Facilities, Reducing Readmissions and Length of Hospital Stays
Summa Health System's Care Coordination Network strives to ensure smooth transitions between the hospitals and 40 local skilled nursing facilities, leading to fewer readmissions and lower length of stay in the hospital.
Michigan Pathways Project Links Ex-Prisoners to Medical Services, Contributing to a Decline in Recidivism
The Michigan Prisoner Reentry Initiative, in partnership with the Muskegon Community Health Project, helps newly released or paroled prisoners access needed health care, contributing to a decline in recidivism.
Show Innovation Attempts
Show Policy Profiles
This Web site, for health care providers, offers “how to” resources on using technology to assist care coordination and improve the independence of older adults.
Suicide: Taking Care of Yourself After an Attempt
This brochure offers information to help patients recovering from a suicide attempt move ahead after their treatment in the emergency department.
Reengineered Discharge Toolkit
This toolkit was developed to facilitate the Project RED intervention.
Interventions to Reduce Acute Care Transfers (INTERACT) Tools
INTERACT is a quality improvement program designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. The goal of INTERACT is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital.
Admission Orders for Medications Prior to Admission
This worksheet can be used to reconcile a patient's current medications and allergies at admission to a hospital.