Advocacy Firm Assists Patients in Choosing Providers/Treatments and Coordinating Care, Leading to Quick Access to Services and High Satisfaction
PinnacleCare provides individualized care management services that include an initial health assessment, an annual health plan/consultation, round-the-clock access to medical advocates and advisers, facilitated access to top specialists and medical institutions, and management of electronic medical records.
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.
Community Partnerships and Provider Training Increase Service Capacity and Access to Long-Term Treatment for Individuals With Heroin Addiction
Community partnerships and provider training increase service capacity and access to long-term treatment for individuals addicted to heroin.
Mental Health Center Provides Integrated Primary Care and Care Coordination to Medicaid Beneficiaries With Severe Mental Illness, Enhancing Access to Services and Improving Outcomes
With support from State funding, a community mental health center provides integrated mental health, primary care, care coordination, and wellness services to Medicaid beneficiaries with severe and persistent mental illness, leading to better chronic disease outcomes.
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.
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Envisioning My Future: A Young Person's Guide to Health Care Transition
This guide, written for youth with special health care needs, helps them prepare for their transition from pediatric health care or service to adult care or service.
Discharge Risk Assessment
This risk assessment tool helps hospital discharge planners fully understand patient needs, thereby avoiding readmissions.
Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) Toolkit
The goal of MARQUIS (Multi-Center Medication Reconciliation Quality Improvement Study) is to develop better ways for medications to be prescribed, documented, and reconciled accurately and safely at times of care transitions when patients enter and leave the hospital.
Department of Veterans Affairs/Department of Defense (VA/DoD) Clinical Practice Guideline for the Management of Major Depressive Disorder in Adults: Inpatient Care Key Points Card
This key points card on inpatient mental health care is derived from the evidence-based clinical practice guideline, Management of Major Depressive Disorder (MDD) in Adults, developed by the Department of Veterans Affairs and Department of Defense (VA/DoD).
Medications At Transitions and Clinical Handoffs (MATCH) Initiative
The goal of the Medications At Transitions and Clinical Handoffs (MATCH) Initiative is to measurably decrease the number of discrepant medication orders and the associated potential and actual patient harm.