Integrated Delivery System Development: Support patients in their homes as they recover following a hospital stay. Assist people in understanding their health conditions, the importance of following hospital discharge instructions, including taking their medications properly, while ensuring they have the medical and social supports necessary to avoid readmission.
Hospital-Homecare Collaboration: Reduce hospital readmissions by introducing enhanced discharge planning tools, care protocols and supports in the home-care setting.
Emergency Department Triage for At Risk Populations: Educate patients on which level of care is best for their needs and help connect them to available care outside of the emergency department.
Care Transition to Reduce 30-Day Readmissions: Decrease the number of times patients are re-admitted to the hospital due to medication errors, infections, or other complications.
Palliative Care Integration into Primary Care: Increase access to palliative care interventions for patients with the greatest need, determined by surveys designed to gauge a patient’s full spectrum of medical, psychosocial, behavioral health and other care needs.
Integration of Behavioral Health and Primary Care: Unite primary care and behavioral health services so primary care doctors have a clearer view of their patients’ overall health. Normalize the process of receiving behavioral health services so it is as easy and comfortable as possible for the patient.
Ambulatory Detoxification: Increase opportunities for withdrawal management services outside of traditional in-patient programs. Train more primary care providers to effectively treat their patients’ addictions.
Strengthen the Mental, Emotional and Behavioral Health Infrastructure: Support collaboration among leaders, professionals, and community members working in MEB health promotion to address substance abuse and other MEB disorders.
Tobacco Cessation: Train primary care providers to address their patients’ use of tobacco and offer medication and other assistance to enable their patients to quit.
Asthma Self-Management: Educate asthma patients, especially children and their caregivers, on how to manage their asthma outside of the doctor’s office, including making the home environment as healthy as possible.
Patient Activation for Uninsured, Under-Insured and Low Utilizers of Health Care: Connect uninsured and non/low utilizing Medicaid patients to primary care and resources through meaningful and lasting coaching relationships, in order to decrease and prevent the number of time patients visit the emergency department unnecessarily.