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).
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.
Managed Care Organization and Visiting Nurse Association Offer Standardized Education to Elderly Heart Failure Patients, Improving Self-Management and Reducing Readmissions
Kaiser Permanente Colorado and the Visiting Nurse Association in Denver jointly offer intense, consistent education to elderly heart failure patients discharged from the hospital in need of home-based skilled nursing care, leading to improved knowledge and self-management skills and fewer readmissions.
Medical Center Establishes Infrastructure to Manage Care Under Capitated Contracts, Leading to Better Chronic Care Management and Lower Utilization and Costs
A university hospital established an infrastructure based on the principles of an accountable care organization, leading to improved management of chronic disease and reduced hospital admissions and medical expenses.
Case Managers Remotely Monitor Chronically Ill Medicare Beneficiaries Each Day, Reducing Mortality and Costs
Case managers remotely monitor Medicare beneficiaries with chronic conditions via a messaging device that asks and records answers to disease-specific and general health questions each day, leading to lower mortality and costs.
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.
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.