What We Tried

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:

• Are unable to schedule a follow-up physician appointment within five days post-discharge from the ED, observation stay or inpatient admission.
• Lack a primary care provider.
• Can’t afford essential medications and/or need assistance managing multiple medications.
• Need assistance securing transportation to health care appointments.
• Can benefit from access to an array of post-acute care resources.

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.

• Community coalition of over 30 local agencies and health care providers.
• Focused on optimizing patient outcomes through improved care coordination, collaboration and communication.
• Targeted improvement of transitions between the hospital and home (medical home, skilled nursing or retirement community).

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.

• Structured to allow patients extended time with the care team.
• Facilitate information processing and dialogue between the patient and the care provider.
• Survey patients on service provision to gain real-time feedback, to address needs as they arise and to identify gaps in services that can be filled by using the network of partners in CalvertHealth CARES.

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.

• Target high utilizers with a focus on patients with heart failure, chronic obstructive pulmonary disease, diabetes, pneumonia or multiple comorbidities.
• Readmission root cause analysis (RCA) patient interviews and chart reviews.
• Potentially avoidable admission RCA patient interviews and chart reviews.

Project Phoenix

In August 2015, CHMC and the Calvert County Health Department partnered to target patients needing mental health and substance abuse services.

• Provides care management coaching and medication management guidance via phone calls and in-person coaching sessions with a social work case manager.
• Readmission RCA patient interviews and chart reviews.

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.

• Provision of safe, quality patient care in an optimal setting.
• Awareness, education and accessibility of Calvert Health System and community-based programs and resources.
• Community support and guidance in developing and implementing multifaceted care plans.