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).
Medical "Extensivists" Care for High-Acuity Patients Across Settings, Leading to Reduced Hospital Use
A Medicare Advantage plan uses employed "extensivists" who perform traditional hospitalist functions for a smaller-than-average caseload of patients, and then continue to follow and care for these patients after discharge until their condition becomes stabilized, leading to low length of stay and fewer readmissions.
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.
Coordinated, Intensive Medical, Social, and Behavioral Health Services Improve Outcomes and Reduce Utilization for Frequent Emergency Department Users
Intensive, concurrent medical and behavioral health care, addiction services, and social service coordination improve patient outcomes and reduce health system use among patients who historically have been frequent users of emergency departments.
Counseling and Care Coordination for Patients With Advanced Illness Lead to More Patients Completing Advance Directives and Less Use of Inpatient Care
Counseling and care coordination for patients with advanced illnesses improved patient–provider communication and the quality of medical care and decisionmaking support, leading to more patients completing advance directives and lower inpatient care requirements.