Emergency Department–Based Case Managers Throughout County Electronically Schedule Clinic Appointments for Underserved Patients, Allowing Many to Establish a Medical Home
Emergency department–based case managers at nine Milwaukee hospitals use electronic technologies to schedule and track attendance at follow-up clinic appointments for low-income, uninsured patients who come to the emergency department with nonurgent needs, allowing many such patients to establish a medical home.
Health Navigators Support Self-Management With Primary Care Patients, Leading to Improved Behaviors and Lower Utilization
Health navigators help primary care patients access medical and community resources, leading to significant improvements in health-related and self-management behaviors and health outcomes and to meaningful declines in emergency department and inpatient utilization.
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.
Parent Consultants Help Families Who Have Children With Special Needs Access Needed Services, Leading to Lower Health Care Utilization and Costs
The Pediatric Practice Enhancement Project places parent consultants in primary care practices to help families with special needs children navigate the health care system and access community-based psychosocial and financial services.
Teams of Diabetes Educators Regularly Visit Rural Clinics to Coach African-American Patients, Leading to Better Glycemic Control and Potential Cost Savings
A traveling team of certified diabetes educators (including a nurse, pharmacist, and dietitian) regularly visits rural clinics to help coordinate diabetes care with clinicians and educate and coach African-American patients with diabetes, leading to improved glycemic control and the potential for meaningful cost savings.
A Family Guide: Integrating Mental Health and Pediatric Primary Care
This guide for families provides practical information about the integrated care movement and how this approach can improve the quality of care children receive in pediatric primary care settings.
Safety Net Medical Home Initiative: Resources and Tools
This library of publicly available resources and tools can help safety net providers understand and implement the patient-centered medical home model of care.
Maximizing Health Care for Colorado’s Underserved
This operational handbook for safety-net medical homes describes the experience of Doctors Care, a community-funded, nonprofit organization that helps underserved children, adults, and families receive the medical attention they need.
National Center of Medical Home Initiatives for Children With Special Needs Tools/Resources
This Web site includes a variety of tools for families, youth, providers, insurers, communities, and States working to provide medical homes for children with special needs.
Practice Facilitation Handbook: Training Modules for New Facilitators and Their Trainers
The Practice Facilitation Handbook is designed to assist in the training of new practice facilitators as they begin to develop the knowledge and skills needed to support meaningful improvement in primary care practices.