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Our Community-Based Care Management (CBCM) program is based on an inclusive definition of health and well-being. We recognize the direct impact non-clinical factors have on medical outcomes and we believe that a patient’s health status is multifaceted. This includes addressing medical, social, psychological and functional needs across the continuum of care. 

By forging relationships with non-traditional community stakeholders/care providers and sharing resources, our CBCM program helps communities realize and accomplish their health goals.  

We help reduce avoidable healthcare use by addressing both psychosocial factors and medical complexities. We empower patients at high risk for these situations by engaging them in their own care and providing comprehensive community-based services in their home using Community Health Workers (CHWs).

Our CHWs specialize in care coordination with community resources including, but not limited to, medical, psychological, rehabilitation or social services. We engage patients in a relationship based on mutual trust and respect, linking them to existing resources in the community. This empowers individuals and entire communities to manage their health conditions while reducing dependence on unnecessary and high-cost hospital services.

In February 2015, Maxim implemented a variation of our CBCM program model in partnership with a major medical center in the Baltimore area to reduce unplanned 30-day readmissions. Focusing on high-risk patient populations, Maxim has to-date provided well over 2,300 NP assessments, 1,500+ RN assessments, and 14,000+ hours of home-based CHW support, reducing readmissions by nearly 66% in its first two years. The program has also achieved a very high acceptance rate given that roughly 65% of patients discharged from the hospital into the program end up accepting the outpatient services in the home.   

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