Our recipes are primers that will help you explore and implement care strategies to benefit your providers, patients, and practice. You can search for the available recipes by keywords, or browse using the filters below.

TOPS: Telephonic Outreach in the Pulmonary Service @ Boston VA

TOPS utilizes nurse-driven, phone-based outreach to improve transitional care, decrease requirements for in-person follow-up, and decrease readmission among COPD patients.

Innovators

  • Sohera N. Syeda, MD
  • Ronald Goldstein, MD
  • Emily Jansen, MPH
  • Catherine Lafferty, MPH
  • Claire Murphy, RN
  • Kristine Sears, RN, RRT
  • Emma Trucks, MPH

Improving Timely Referrals via implementation of Lower Extremity Amputation Prevention (LEAP) Tool @ Suburban Wound Care Clinic

This program sought to standardize diabetic ulcer assessments and timely referral to vascular/podiatry services.

Innovators

  • Azam Tayyebi DNP

Emergency Department Discharges to Medical Home @ Carolinas HealthCare System Anson

Implementation of the Discharge to Medical Home model, a new care delivery model that routes non-urgent ambulatory emergency department (ED) patients to a nearby primary…

Innovators

  • Kathryn Zager, MS
  • Yhenneko J. Taylor, PhD

Nurse Billable Visits @ Mary’s Center FQHC

Establishing a protocol and workflow to capture value for the Federally Qualified Health Center by billing for nurse-led education visits

Innovators

  • Dara Koppelman, MS, BSN

Opioid Management via Group Visits @ Boston Medical Center

Group visits combining behavioral health therapy and pharmacologic support for patients with substance/opioid use disorder with an emphasis on community support and accountability.

Innovators

  • Shari Zakim-Yacouby LICSW
  • Tu-Mai Tran MD
  • Marielle Baldwin MD MPH
  • Huong Tran MD
  • Beth Marx MSW, LICSW
  • Krystyna Roszczenko, Team Coordinator

Nurse Billable Visits in Primary Care @ Unity Health Care

Unity Health Care incorporated nurse billable visits into its community health center practice in order to increase nurses’ roles in patient care and improve patient…

Innovators

  • Janine Resilard, MSN-Ed, RN

Screening, Brief Intervention, & Referral to Treatment for Social Determinants of Health @ Intermountain Health Care

Intermountain Healthcare created a Social Determinants of Health Committee in order to devise a strategic plan with which to address social determinants of health for…

Innovators

  • Elizabeth Joy, MD MPH FACSM

Diabetes Population Health Management @ Massachusetts General Hospital

Use of population health coordinators to optimize care for patients with diabetes

Innovators

  • Blair Fosburgh MD

Teaming in Primary Care @ University of Vermont’s Aesculapius Medical Center

Development of a team-based care process at a small suburban primary care practice

Innovators

  • Alison Landrey MD

Diabetes Management via Food as Medicine “Fresh Food Farmacy” in Primary Care @ Geisinger Health System

Fresh Food Farmacy is an organization that works improve the health of diabetic adults by providing them with free, nutritious food in addition to traditional healthcare…

Innovators

  • Andrea Feinberg