The Coordinating Center will lead a bold new approach to helping people with chronic illnesses avoid readmissions to hospitals and achieve better health at home. The WBRRC is reimbursed through the Center for Medicare & Medicaid Services (CMS). The purpose of the program is to help hospitals with high readmission rates to partner with a community based organization to provide care transition services to improve a person`s transition from the hospital to other care settings. The program was created by Section 3026 of the Affordable Care Act to test models for improving care transitions for high risk Medicare patients.
In Maryland, the collaboration is a joint effort of The Coordinating Center, the University of Maryland Medical Center (UMMC), Maryland General Hospital, Bon Secours Hospital and Baltimore City Aging and Disability Resource Center. The people who live in the area of West Baltimore served by the hospitals exhibit higher incidences of diagnoses such as pneumonia, chronic heart failure, Chronic Obstructive Pulmonary Disease, End Stage Renal Disease, Acute Myocardial Infarction and Septicemia putting them at risk for hospital readmissions. Also, this economically depressed area reflects not only lower health outcomes but also shorter life expectancy.
The new service implemented by The Coordinating Center, GET WELL is designed to help people who are discharged from the hospital. Hospitals will refer people to Health Coaches who will partner with high risk Medicare recipients and their families by helping them to recognize “red flags” related to the person`s condition, reviewing current medicines, providing personal health records and assisting with access to community resources. The Health Coach will begin working with the individual at the hospital and then will visit again at home, and will also maintain contact for 30 days post discharge.
Karen Ann Lichtenstein, Executive Director of The Coordinating Center, states that “we are committed to supporting people and the community to manage their health needs and improve the quality of care.” In addition to working with these individuals to achieve better health at home, the health coach will refer people to resources that support their ability to GET WELL . “We are honored to help people with access to services that can reduce hospitalizations,” Lichtenstein continued.
For nearly three decades, The Coordinating Center, a non profit organization, has provided care coordination among people of all ages with the most complex medical concerns and disabilities. Located in Millersville, Maryland, The Center is accredited for case management by URAC (Utilization Review Accreditation Commission), a national case management certification agency. The Center is also certified by the Maryland Nonprofits` Standards for Excellence, a rigorous ethics and accountability program.
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