The Coordinating Center is helping individuals with chronic illnesses avoid hospital readmission and achieve better health at home.
The West Baltimore Readmissions Reduction Collaborative (WBRRC) is a joint effort of The Coordinating Center, the University of Maryland Medical Center Main Campus, the University of Maryland Midtown Campus, Bon Secours Hospital and Baltimore City Aging and Disability Resource Center. WBRRC is a Community Based Care Transition Program (CCTP) targeting Medicare participants who are at high risk of hospital readmission.
Since its inception, the WBRRC has significantly reduced the rate of all cause hospital readmissions occurring within thirty days of discharge and more than 2,000 clients received The Coordinating Center’s GET WELL transition services, using the evidence-based Coleman Transition Model.
The Center has a GET WELL team in each of the three hospitals. 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.
Many people who live in West Baltimore and are 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. This economically depressed area reflects not only lower health outcomes but also shorter life expectancy.