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Innovations : connectingpatients-medicalhomes

Integrated Programs

Title:  Connecting Patients with Medical Homes program


Organization: Calvert Memorial Hospital  connectinpatients-graph.jpg

Innovation Type: Care Connections supported by Total Patient Revenue  

What They’re Doing: Connecting high-risk/ high utilizing patients with medical homes supported by Total Patient Revenue.  

Clinical Innovation: Calvert Memorial Hospital identifies patients who are uninsured, underinsured patients, high risk, or have frequent hospitalizations or emergency department visits and helps connect them with primary care physicians and medical homes that can appropriately manage their care. The program focuses on educating patients about the availability of different health care settings and improving patient access to primary and preventive care services.  

Financing Mechanism: Under the Total Patient Revenue program, Calvert Memorial Hospital receives a global budget or capitated payment that covers all inpatient and outpatient services provided by the hospital, providing incentives to keep patients healthy and out of the hospital. The program is currently funded entirely by the hospital system.  

Evaluation Plan: Evaluating the program based on the percent of patients that visit the ED without a PCP and the readmission rate for the population enrolled in the program.  

Patient Health and Cost Outcomes:  

  • Reduced ED Visits: Since the program began, CMH has seen a 15 percent reduction in ED visits for patients without a primary care physician.  

  • Reduced readmissions: After six months, January 2011 through June 2011, the initial results have been very encouraging.   Of the more than eighty patients being managed by the care coordinator, 87% of patients receiving care coordination did not return to the hospital within 30 days. 

  • Publications: None 

Target Population:   Patients who are uninsured, underinsured patients, high risk, or have frequent hospitalizations or emergency department visits  

Date of Implementation: January 2011. Approximately 80 patients.  

Contact: Jennifer Young, Director of Case Management at Calvert Memorial Hospital, 410-535-8217,

Multimedia: Pending  

Where to learn more: Please contact Jennifer Young,



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