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The Veterans Health Administration (VHA) Stratification Tool for Opioid Risk Mitigation (STORM) decision support system and targeted prevention program were designed to help mitigate risk factors for overdose and suicide among veterans who are prescribed opioids and/or with opioid use disorder (OUD) and are served by the VHA.1 Veterans, particularly those prescribed opioids, experience overdose and suicide events at roughly twice the rate of the general population.1,2

The MOQI seeks to reduce avoidable hospitalization among nursing home residents by placing an advanced practice registered nurse (APRN) within the care team with the goal of early identification of resident decline. In addition to the APRN, the MOQI involves nursing home teams focused on use of tools to better detect acute changes in resident status, smoother transitions between hospitals and nursing homes, end-of-life care, and use of health information technology to facilitate communication with peers. As a result of the innovation, resident hospitalizations declined.

Care management staff (such as nurses, community health workers, health coaches, social workers, or other clinical staff) use software-based protocols to screen older clients' medications and collaborate with pharmacists and physicians to reduce the risk of medication errors and adverse effects. The HomeMeds Medication Safety Program identified and addressed targeted medication problems, leading to fewer cases of therapeutic duplication and more appropriate medication use for cardiovascular medications, NSAIDS, psychotropics and overall medication use.

Project Nurture provides patients with substance use disorder (SUD) prenatal care, inpatient maternity care, postpartum care, and infant pediatric care. Women enrolled in the program receive Level 1 addiction treatment (i.e., outpatient services) from an integrated care team that includes MDs, nurse practitioners, doulas, certified recovery mentors, certified alcohol and drug counselors, and social workers and other mental health professionals. If indicated, they can also receive medication-assisted treatment (MAT) using methadone or buprenorphine.

The team at Geisinger sought to develop an outpatient addiction medicine specialty program that incorporated medication-assisted treatment (MAT), peer support, and connection to community counseling services that also uses data-driven insights to monitor and improve patient outcomes. As a result of this program, they have been able to reduce all-cause mortality among these patients, increase patient engagement in substance use disorder treatment, and have seen a reduction in the prescription quantities of controlled substances.

The Support and Services at Home (SASH®) program provides onsite assistance to help senior citizens (and other Medicare beneficiaries) remain in their homes as they age. Using evidence-based practices, a multidisciplinary, onsite team conducts an initial health assessment, creates an individualized care plan based on each participant’s self-identified goals, provides onsite nursing and care coordination with local partners, and schedules community activities to support health and wellness.