Case Management and Home Assessments Reduce Asthma-Related Admissions, Emergency Visits, and Missed School Days in Diverse Urban Children
Case management combined with in-home environmental assessment and remediation of environmental triggers reduce asthma-related hospitalizations, emergency department visits, missed school days, and missed parent work days in diverse, low-income urban children with asthma.
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.
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).
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.
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.
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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.
Coordinated-Transitional Care Toolkit
The goal of this toolkit is to help hospital systems that serve populations with high rates of patient dispersion, cognitive impairment, and vulnerability improve care coordination and postdischarge outcomes such as reduced medication discrepancies.