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.
Palliative Care Nurses in Primary Care Clinics Reduce Hospital Admissions, Increase Use of Hospice and Home Care for Patients Nearing End of Life
A partnership between a hospice organization and an 11-location multispecialty group practice places palliative care nurses in primary care clinics to monitor dying patients' medical and social care needs, coordinate community services, and discuss end-of-life issues.
Self-Directed Budget for Health and Other Services Enhances Ability of Those with Mental Illness to Function and Live Independently
A state-funded program gives individuals with mental illness a quarterly allowance for mental health and wellness services that can be spent at their own discretion, allowing them to spend more time living in the community and to function more effectively.
Community Partnership Connects Low-Income Patients With Providers Who Serve Them at Discounted Rates, Enhancing Access and Reducing Emergency Department Use
A nonprofit, community-based organization matches uninsured and underinsured patients with physicians, hospitals, and other providers who agree to serve them at reduced fees and provides various sources of support to both providers and patients, leading to enhanced access to care and fewer emergency department visits.
Hospital Uses Data Analytics and Predictive Modeling To Identify and Allocate Scarce Resources to High-Risk Patients, Leading to Fewer Readmissions
A safety net hospital employs a software application that uses electronic health record data and predictive modeling to identify and allocate scarce resources to high-risk patients, leading to fewer readmissions and lower 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.
Establishing a Child Health Improvement Partnership: A How-to Guide
This guide attempts to share the best thinking and knowledge about what existing IPs have been able to accomplish.
This Web site, for health care providers, offers “how to” resources on using technology to assist care coordination and improve the independence of older adults.
Interventions to Reduce Acute Care Transfers (INTERACT) Tools
INTERACT is a quality improvement program designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. The goal of INTERACT is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital.
Care Coordination: Strategies to Reduce Avoidable Emergency Department Use
The purpose of this guide is to offer advice and interventions that practices can use to help their patients reduce avoidable emergency department visits.