Reducing Hospital Readmissions

Patients are often discharged from the hospital without the needed community support in place, resulting in either declined health or a rehospitalization. We have developed a comprehensive solution to this problem using an interdisciplinary team of nurses, Community Health Workers and other program professionals.

We work in collaboration with the patient, caregivers, providers, and community resources to create an individualized, holistic approach to maintaining health that promotes:

  • Improved patient outcomes in the comfort of their own home
  • Primary care appointment coordination
  • Reduced hospital utilization

Preventing Rehospitalization

The transition from hospital to home can be overwhelming and complicated, potentially leading to readmission. To help prevent this, we have assembled a Community-Based Care Management team that will provide support services designed to assist patients on the road to recovery after discharge from the hospital.

Next Steps

The goal of our team is to coordinate primary care along with community and social resources after the hospital stay. Once discharged, patients are visited in the home by one of our registered nurses. This nurse will conduct an in-person review of discharge plans and current medications, develop a personalized care plan and begin to help support recovery. Next, a Community Health Worker will be assigned to identify and connect the appropriate resources. These services will help the patient better manage their health, thereby improving or maintaining their current status.

Services Offered

Community-Based Care Management program candidates may be able to benefit from the following support services:

  • Securing a primary care and/or specialty care provider
  •  Coordination with healthcare providers
  • Medication reconciliation
  • Health education reinforcement
  • Navigating the health insurance system
  • Resources for patient-specific needs such as nutrition, transportation, financial and social support
  • Identify the need for additional post-discharge support services

Proven Effective

We successfully implemented a program in partnership with the University of Maryland St. Joseph Medical Center, near Baltimore, to reduce unplanned 30-day hospital readmissions. Focusing on high-risk patient populations, we helped reduce readmissions by nearly 66% in our first two years.