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.

Interdisciplinary Care Program for Patients with High Needs & Costs in a Primary Care Setting @ Froedtert and The Medical College of Wisconsin

In 2016, a primary care clinic at Froedtert & Medical College of Wisconsin evaluated two evidenced-based hospitalization prevention models that reduced admissions for high-need and…

Innovators

  • Brian Hilgeman, MD, AAHIVM, FACP

Addiction Care Team (ACT) in an Inpatient Setting @ San Francisco General Hospital

In September 2017, San Francisco General Hospital launched an Addiction Care Team (ACT) program which consisted of an interprofessional inpatient addiction care team embedded in…

Innovators

  • Marlene Martin, MD

Implementation of a Population-Health Mapping Tool @ Lehigh Valley Federally Qualified Health Center

The Neighborhood Health Centers of the Lehigh Valley Federally Qualified Health Center in Allentown, PA implemented an innovative population-health mapping tool to gain a better…

Innovators

  • Autumn M. Kieber-Emmons, MD, MPH

Community-based COVID-19 Test-to-Care Model @ University of California San Francisco

This Test-to-Care Model (T2C) was developed and evaluated by a research team from the University of California San Francisco (UCSF) in conjunction with local community…

Innovators

  • Andrew Kerkhoff, MD, PhD

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