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.

A Home-Based Palliative Care Program via Virtual Visits @ 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…

Innovators

  • Dana Lustbader, MD
  • Mitchell Mudra, MBA
  • Carole Romano
  • Ed Lukoski
  • Andy Chang
  • James Mittelberger
  • Terry Scherr

Improving Transition Care via EHR Hospital Use Data @ Northwestern Medicine Group Transitional Care Clinic

The Northwestern Medicine Group Transitional Care clinic (NMG-TC) seeks to reduce preventable re-hospitalization by implementing a model of intensive case management and integrated behavioral/medical healthcare…

Innovators

  • Joe Feinglass PhD
  • Celeste A. Mallama PhD MPH
  • Angela Rogers MPH, APN-CNP
  • Caroline Teter PA
  • Courtney Hurt LCSW
  • Christine Schaeffer MD

Integrating Behavioral Health via Behavioral Health Consultant Roles @ Jefferson Health

Jefferson Health implemented a system-wide integrated behavioral health (IBH) program that introduces behavioral health consultants (BHCs) into practices across Jefferson Health in an effort to…

Innovators

  • Christine Arenson, MD
  • Amy Cunningham, PhD, MPH
  • Johnny Stoeckle, MD

Intensive Primary Care via Patient Aligned Care Teams (PACT) Intensive Management @ the Veteran’s Health Administration

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…

Innovators

  • Evelyn Chang, MD, MSHS
  • Lisa Rubenstein, MD, MSPH

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…

Innovators

  • Ellen Fox, MD
  • Paul Tompkins
  • Mary Beth Foglia, RN, PhD, MA
  • Jill Lowery, PsyD
  • Virginia Ashby Sharpe, PhD

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…

Innovators

  • Shreya Kangovi, MD, MS
  • Scott Tornek, MBA
  • Olenga Anabui, MBA, MPH
  • Jill Feldstein, MPA
  • Tamala Carter

Engaging Substance Use Disorder (SUD) Patients in Outpatient Care via Implementation of Recovery Coaches @ Arms Acres

This project aimed to demonstrate the value of adding recovery coaches to the multidisciplinary team at Arms Acres in order to improve transitions of care…

Innovators

  • Tamar Wolinsky
  • Eric D’Entrone
  • Tammy Bender
  • Eric Altman
  • Damara Gutnick, MD
  • Kristin Woodlock, RN

Improving Care Coordination via Johns Hopkins Community Health Partnership (J-CHiP) @ Johns Hopkins Medicine

Johns Hopkins Community Health Partnership (J-CHiP) is a three-pronged care coordination program with comprehensive community support for a cohort of high-risk patients, enhanced discharge procedures…

Adoption of Social Determinants of Health EHR Tools by Community Health Centers in the Pacific Northwest

This pilot study assessed the feasibility of implementing EHR tools for collecting, reviewing, and acting on patient-reported social determinants of health in three community health…

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