Androscoggin Home Care & Hospice has developed M.O.D.E.L. Care, a unique operational system design that propels change in culture, clinical practice, support services and partner relationships in a highly reliable way. The impact has been dramatic — consistent improvement in outcomes, patient satisfaction, internal audits and reduced canceled visits.

Sutter Care at Home's Integrated Care Management (ICM) is a patient-centered, evidence-based care delivery model with care coordinated across providers, settings, and time. By developing this standardized ICM system based on best practices, Sutter has changed both provider and patient behavior to reduce hospitalization rates, 30-day readmissions, and emergent care utilization; and improve HHCAHPS measures and employee engagement.

VNS at St. Francis' Patient Health Coaching Program combines certified Health Coach RNs with telehealth monitoring and kiosks throughout the service area, dramatically reducing
re-hospitalization rates for high risk patients. The program's success has increased exposure to potential clients and led to a key ACO relationship, establishing a new payer in the VNS system.

By combining daily patient contact with historical clinical and demographic information, CareCycle Solutions has deployed appropriate interventions for its chronically ill patients. Using a disease acuity score, important changes are highlighted so that clinicians can act promptly, saving the cost of unnecessary visits and reducing re-hospitalizations.

Developed originally as a means to support residents in Bethesda's long term care communities, Bethesda's Home Health Geriatric Care Management program has become so effective it has been expanded to support seniors in other community-based settings. In addition to providing a vital service for seniors, Bethesda helps these communities retain their residents and improve census, resulting in dramatic financial improvements.