This toolkit provides resources to assist organizations in managing patient information exchanges between the various providers involved in a clinical care team. It also offers examples of state behavioral/physical health coordination consent forms.
This brief, prepared by Bailit Health Purchasing and the Robert Wood Johnson Foundation, examines practical approaches that state agencies might employ to better integrate social services and health care delivery.
The primary objective of this study presented in AcademyHealth was to identify key organizational approaches associated with underuse of breast cancer care in nine New York City area safety-net hospitals. The study concluded that at safety-net hospitals, underuse of needed cancer therapies is associated with organizational approaches to track and follow-up treatment. Findings provide varying approaches to safety nets to improve cancer care delivery.
Funded by the DentaQuest Foundation, this initiative is a partnership with the National Association of Community Health Centers and Massachusetts League of Community Health Centers. The partnership is working with 15 state Primary Care Associations and over 100 Community Health Centers to strengthen local and state oral health programs.
The paper was produced by the Center for Health Care Strategies and the State Health Access Data Assistance Center (SHADAC) with support from the Center for Medicare & Medicaid Innovation (the Innovation Center). This resource paper provides information on Community Care Team programs in several states and includes: An overview of core program features, key elements of governance models, approaches to financing and reimbursement, considerations for workforce requirements, and examples of health informatics models to support CCT initiatives.
The Health Care Transformation Taskforce published this white paper, which provides information on the building blocks of care management; reviews case studies of Task Force member care management programs, and lessons learned and important areas for improvement.
This brief published by the Center for Health Care Strategies was developed through support from The Commonwealth Fund and The SCAN Foundation. The technical assistance brief describes key interdisciplinary care teams (ICTs) considerations and explores how eight states – Idaho, Massachusetts, Minnesota, New Jersey, New York, Rhode Island, Virginia, and Washington – addressed these issues.
This Commonwealth Fund article describes a study of medical practices recognized as patient-centered medical homes found that a team approach to primary care was fostered by: delegating more of physicians’ nonclinical tasks to other staff; soliciting staff input on workflow modifications and feeding back data to the team; expanding the roles of medical assistants and nurses; and holding regular team “huddles.”
This scholarly article provides insight into strategies to promote care integration in the safety net. The researchers interviewed safety net hospital and health center leaders from five US cities to understand specific strategies implemented by their organizations.
This issue brief from The Commonwealth Fund establishes the drivers, goals, and challenges of forging community partnerships from the perspective of four Medicaid managed care organizations.
This article from The Commonwealth Fund offers evidence to support the value in partnerships between accountable care organizations and community health centers.
This scholarly article documents the effects of implementing a patient navigator program in a safety net hospital on hospital readmission rates.
This scholarly article investigates the impact of care coordinators and clinical pharmacists in rural FQHCs on care for patients covered by both Medicare and Medicaid. The study indicates that investments in care coordination and clinical pharmacy review can significantly reduce hospitalization and harmful polypharmacy in this patient population.
This scholarly article evaluates the impact of chronic care coordinators on diabetes care quality within six community health centers. The chronic care coordinator intervention in this study yielded some improvement, but requires some modification.
This report from The Commonwealth Fund offers a financial argument to support the need for health care providers to address patient’s social needs. It also provides strategies for health care organizations to achieve this goal.
This report explores the effectiveness of a disease management (DM) program for early childhood caries. The DM clinical protocol included a caries risk assessment tool (CAT), in-office and at-home care management, and other tools. The results from this analysis indicate that a risk-based DM approach may improve health care quality and patient outcomes. Safety net oral health providers can use this report to improve care for early childhood caries.
This report investigates the cost-effectiveness of a disease management (DM) program for early childhood caries. The study concludes that the DM program is cost-effective and may reduce overall health care costs. Safety net oral health providers may use this report to financially justify a DM intervention for early childhood caries.
Safety Net Solutions is a DentaQuest Institute program that seeks to provide care management assistance to safety net dental programs. This report outlines the SNS model and its impact, as well as provides lessons and recommendations based on efforts from 2006- 2011. Safety net providers may use this report to improve their dental programs.