Individualized Care Delivery in Primary Care via Integrated Practice Units (IPUs) @ Cambridge Health Alliance Union Square Family Health Center
This intervention sought to adopt integrated practice units (IPUs) into a primary care practice using ‘pod’-based patient care with a multidisciplinary team, disease-oriented patient registries,…
Treating Opioid & Alcohol Use Disorders (OAUD) via Collaborative Care @ Venice Family Clinic FQHC
A randomized control trial examined the impact of a collaborative care intervention in primary care patients with opioid and alcohol use disorders (OAUD) vs. primary…
Reducing Clinician Burden via Team-Based Labs Ordering @ Iora Health
This project aimed to increase efficiency by having health coaches attend office visits with clinicians to document lab orders in the electronic health record during…
Improving Discharge Coordination in Integrated Behavioral Health (IBH) Settings via ‘Health Systems Genogram’ Patient Assessment Tool @ Saint Louis University Family and Community Medicine
This project aimed to improve follow-up care for Integrated Behavioral Health (IBH) patients being discharged from the hospital through Health Systems Genogram, an electronic, provider-facing…
Intensive Primary Care via Patient Aligned Care Teams (PACT) Intensive Management @ VA
The VA currently offers primary care through patient-centered medical homes, or Patient Aligned Care Teams (PACT) for all enrolled Veterans. Selected demonstration sites augmented the…
Improving Advance Care Planning via the Life-Sustaining Treatment Decisions Initiative (LSTDI) @ US Department of Veteran Affairs
The VHA aims to improve care for patients with advanced illness and at heightened risk of a life-threatening event by promoting high-quality Goals of Care…
Home-Based Palliative Care (HBPC) Program @ ProHEALTH Care ACO
ProHEALTH Care, a New York-based ACO, developed a program for high-need patients that employs home nursing visits, telehealth appointments with palliative care physicians, and other…
Employing Community Health Workers (CHWs) to Improve Population Health via the IMPaCT Model @ Penn Center for Community Health Workers
The IMPaCT (Individualized Management of Patient-Centered Targets) model is a standardized, scalable, evidence-based Community Health Worker (CHW) intervention proven to improve chronic disease control, quality…
Implementing an Interdisciplinary Collaborative Experience in Diabetes Care @ People’s Community Clinic
People’s Community Clinic (PCC) created an interdisciplinary approach to overcome barriers to diabetes self-management by integrating nurses and health educators specialized in diabetes education into…
Improving Multicultural Depression Screening and Follow-up via Multilingual and Standardized Tools @ Harrisonburg Community Health Center
This quality improvement project aimed to improve depression management by offering both universal screening in several languages and additional tools for treatment decision-making and follow-up…