Title: The Readmission Program
Organization Name: Maryland Physicians Care
Innovation type: Care Transitions
What They’re Doing: Providing additional support for high risk/ high cost patients as they transition out of the inpatient setting.
Clinical Innovation: Identifies high risk/ high cost patients in the hospital on the basis of medical claims history and diagnosis and conducts outreach to enroll them into the program prior to discharge. Prior to Discharge, a “Discharge Advocate” educates the patient about the discharge plan, helps the patient fill appropriate medications, schedule follow up appointments, and develops a “ Provider Information Form” that facilitates communication with the provider during discharge planning. After being released from the hospital, the patient receives a home visit and/or telephone reinforcement (ELIZA) within 48-72 hours post discharge and follow up calls once per week for 3 weeks.
Maryland Physicians Care also sends daily inpatient census report to the participating hospitals; identifying the high risk/high utilizers which enables the hospital to focus their resources on that population.
Evaluation Type: Quasi-Experimental .
Evaluation Plan: Tracking the 30 day readmission rate before and after the implementation of the program. ED utilization, follow up appointments and medication adherence.
Patient Health and Cost Outcomes:
Target Population: High risk/ high cost patients admitted to Maryland General Hospital, St Agnes Health System, Western Maryland Health System and Meritus Medical Center .
Date of Implementation: January 2011
Contact: Mary Leitch, firstname.lastname@example.org , 410-401-9586
Where to learn more: Please contact Mary Leitch.