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Through patient, caregiver, community and team collaboration, CalvertHealth Medical Center created a program to educate, engage and empower patients.
CalvertHealth Medical Center (CHMC) was challenged with developing an innovative plan to address high utilizer recidivism in the ED and inpatient settings. Early success with the Transitions to Home Program resulted in readmission targets being significantly decreased. To identify resource access gaps, CHMC called on its “village” (local health care coalition and their case management team of acute care and emergency department nurses and social workers) to identify opportunities for program enhancement by using a SWOT analysis. Medication and medical supply affordability, transportation access and other social determinant-related opportunities were identified.
CalvertHealth Medical Center (CHMC) is a 94-bed independent, not-for-profit community hospital. CHMC provides general medical-surgical, psychiatric and post-acute skilled and rehab care. Approximately 1,200 dedicated employees help CHMC provide the very best for patients, with more than 200 volunteers helping to add those “special touches.” In addition to the medical center campus, four satellite medical office buildings ensure that quality care is no more than 15 minutes from anywhere in Calvert County.
CHMC created CalvertHealth CARES, a free community benefit program that takes a multifaceted approach to meet the post-discharge needs of patients by assisting patients at moderate to high risk for readmission or emergency department overuse. CARES stands for Collaborative Activation of Resources and Empowerment Services.
CalvertHealth CARES bridges the gap for patients who:
CalvertHealth CARES consists of several components and interventions:
Partners in Accountable Care Collaboration and Transitions (PACCT)
Since October 2013, PACCT members have created a forum for sharing best practices, increasing awareness of housing options for seniors and creating solutions to improve patient outcomes and patient experience.
CalvertHealth CARES Clinic
The discharge clinic focuses on care management coaching, health status assessment, goals building, intervention planning, medication therapy management, psychosocial support and resource access.
Transitions to Home (T2H)
T2H provides health management coaching and medication management guidance via phone calls and home visits. Pharmacist medication therapy management home visits are a significant part of the program. Target population is patients with somatic health challenges.
In August 2015, CHMC and the Calvert County Health Department partnered to target patients needing mental health and substance abuse services.
Medication Assistance Program (MAP) and Transportation Assistance Program (TAP)
CHMC utilizes hospital funded financial assistance programs to help patients pay for essential medications, medical supplies or transportation to medical appointments.
CARES Grand Rounds
This community-focused committee serves in an advisory capacity to facilitate identification of potential solutions to care challenges and gaps for high utilization group patients.
CalvertHealth CARES has greatly contributed to CHMC’s lowered readmission rate. CHMC ended 2016 with an average risk-adjusted readmission rate of 8.83 percent, one of the lowest readmission rates in Maryland.
All-Cause, Intrahospital, Non-Risk Adjusted Readmission Reduction Trends FY 2014 – FYTD 2017
CHMC’s all-cause aggregate, nursing home and Medicare readmissions have significantly trended down over the past three years, with the most recent decrease occurring when they opened their second CARES Clinic.
Risk-Adjusted Aggregated Inter- and Intrahospital Readmissions for CY 2016
CHMC not only met their targets for 2016, they also ranked as one of the best hospitals in Maryland for readmissions avoidance.
The CalvertHealth CARES clinic team saw 165 patients last year. Less than 4 percent of them returned to the hospital within 30 days of discharge.
CHMC recently added palliative care, using a contracted hospice physician as a consultant, and a CMH Palliative Care Coordinator, who is a certified Palliative Care social worker on the Case Management Team. This has improved the quality of life for terminally ill patients as well as reducing readmissions.
Patient and Family Challenges: Empowering Patients, Going to Follow-up Appointments, Next Steps After Leaving the Hospital, Not Receptive to Home Visits, Social Challenges, Understanding Medication Instructions
Organization Name: CalvertHealth Medical Center
Location: 100 Hospital Rd, Prince Frederick, MD 20678, United States
Organization Type: Community organization
Organization Model: Not Set