Disease Management Programs Improve Adherence to Evidence-Based Processes and Outcomes by Targeting Sickest Patients and Working Closely With Physicians
A hospital-based outpatient disease management program serves patients with asthma, chronic heart failure, and diabetes and offers smoking cessation services to smokers. Unlike traditional disease management programs, this initiative heavily involves physicians in the initial referral and throughout the process and targets services toward the sickest patients (rather than to all patients with the condition).
Postdischarge Care Management Integrates Medical and Psychosocial Care of Low-Income Elderly Patients
An interdisciplinary care management program that integrates medical and social care for low-income elderly patients with chronic illnesses reduces care costs and improves self-reported health status.
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.
Heart Failure Disease Management Improves Outcomes and Reduces Costs
Essentia Health Heart and Vascular Center created a heart failure program combining chronic care and disease management principles to improve outcomes and reduce costs associated with heart failure care.
Hospital-Based Heart Failure Nurse Advocate Reduces Readmissions and Hospital Costs
A trained nurse educated other nurses, physicians, and administrators on evidence-based heart failure treatment and provided disease management education and followup support to high-risk patients, leading to fewer readmissions and lower costs.
Expecting Success Toolkit
The Expecting Success Toolkit provides tips for hospitals on improving the quality of care and reducing disparities.
Heart Failure Self-Management—Caring for Your Heart: Living Well With Heart Failure
These health communication aides for clinicians can help them demonstrate to patients that organized self-management support can improve self-care behaviors and prevent hospitalizations.
Develop Your "Hospital At Home" Program
"Hospital At Home" is an innovative health care model that can provide hospital-level care in a patient’s home as a full substitute for acute hospital care until the patient is ready for discharge to their primary care physician. The Web site contains information and tools for organizations that are considering starting their own program.
Treating Congestive Heart Failure With Beta Blockers: What You Can Do To Make Yourself Feel Better
This brochure can help patients and their families understand congestive heart failure and current treatments, focusing on the use of a group of medications called beta blockers.
STate Action on Avoidable Rehospitalizations (STAAR) Materials
The STate Action on Avoidable Rehospitalizations (STAAR) Initiative of the Institute for Healthcare Improvement and The Commonwealth Fund aims to reduce avoidable rehospitalizations. This Web site features guides, presentations, and other tools related to reducing readmissions.