The Coordinating Center’s Community Care Transition Program (CCTP) will share its best practices with Lewin and CMS representatives during a two-day onsite visit on January 28 and 29.
In Maryland, the West Baltimore Readmissions Reduction Collaborative is a joint effort of The Coordinating Center, the University of Maryland Medical Center (UMMC) Main Campus, UMMC – Midtown Campus, 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, Congestive 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 Center has a GET WELL team in each of the three hospitals and works to reduce readmission rates. GET WELL Transition Coaches meet with eligible Medicare beneficiaries who are at high risk for readmission while they are still in the hospital. The Transition Coach helps the individual and their family members recognize “red flags” related to the person’s condition, review current medications, provide Personal Health Records and assist with access to community resources. Once the individual has been discharged, the Transition Coach visits them at home to ensure they are taking their medications correctly, scheduling and attending follow-up doctor appointments and to help them create goals to stay healthy and out of the hospital. The Transition Coach remains in contact with the individual for 30 days post-discharge.
“The Coordinating Center Get Well Team is working incredibly hard to improve discharge practices and minimize hospital readmissions for eligible beneficiaries in the West Baltimore area,” said Carol Marsiglia, Senior Vice President, Strategic Initiatives and Partnerships. “Our hospital and Baltimore City ADRC partners are key to the success of this work.”
The Coordinating Center is frequently asked to speak at local and national conferences to share best practices and strategies to minimize readmissions.