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.
Daily Text Messages and Nurse Followup Improve Self-Management Behaviors in Patients with Diabetes, Leading to Better Glycemic Control and Lower Costs
Daily automated text messages combined with nurse followup improved self-management behaviors among patients with diabetes, leading to significant
improvements in glycemic control, fewer doctor visits, lower costs, and high patient satisfaction.
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 Coach Program in a Medical Group Improves Self-Care and Decreases Readmissions for High-Risk, Chronically Ill Patients
Dartmouth-Hitchcock Clinic assigned health coaches to high-risk chronic disease patients to provide instruction regarding health care needs over the phone, during office visits, and in group classes; the program reduced readmission rates and costs among elderly patients.
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.
Show Innovation Attempts
Show Policy Profiles
Discharge Risk Assessment
This risk assessment tool helps hospital discharge planners fully understand patient needs, thereby avoiding readmissions.
Improving Treatment Decisions for Patients With Community-Acquired Pneumonia
This report describes two tools developed by the Agency for Healthcare Research and Quality (AHRQ) funded research that help assess the need for hospitalization of patients with community-acquired pneumonia (CAP) and determine the medical stability of patients prior to discharge.
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.
Managing Drug-Seeking Behaviors & Super Users in the Emergency Department
This guide for emergency department (ED) physicians, nurses, and caregivers includes information and tools for providing pain management care to drug "super users" in the ED.
Medical Respite Tool Kit
The purpose of the Medical Respite Tool Kit is to provide information and tools to help organizations and advocates plan, develop, and sustain medical respite programs. This tool organizes existing resources developed by the National Health Care for the Homeless Council and other medical respite providers while incorporating new and practical tools.