Title: The Readmission Program

Organization Name: Maryland Physicians Care 

Innovation type: Care Transitions 

What They’re Doing: Providing additional support for high risk/ high cost patients as they transition out of the inpatient setting.  

Clinical Innovation: Identifies high risk/ high cost patients in the hospital on the basis of medical claims history and diagnosis and conducts outreach to enroll them into the program prior to discharge. Prior to Discharge, a “Discharge Advocate” educates the patient about the discharge plan, helps the patient fill appropriate medications, schedule follow up appointments, and develops a “ Provider Information Form” that facilitates communication with the provider during discharge planning. After being released from the hospital, the patient receives a home visit and/or telephone reinforcement (ELIZA) within 48-72 hours post discharge and follow up calls once per week for 3 weeks.  

Maryland Physicians Care also sends daily inpatient census report to the participating hospitals; identifying the high risk/high utilizers which enables the hospital to focus their resources on that population.  

Evaluation Type: Quasi-Experimental .

Evaluation Plan: Tracking the 30 day readmission rate before and after the implementation of the program.   ED utilization, follow up appointments and medication adherence.  

Patient Health and Cost Outcomes:  

Publications: None  

Target Population: High risk/ high cost patients admitted to Maryland General Hospital, St Agnes Health System, Western Maryland Health System and Meritus Medical Center .  

Date of Implementation: January 2011

Contact: Mary Leitch, mary.leitch@marylandphysicianscare.com , 410-401-9586

Multimedia: Pending

Where to learn more: Please contact Mary Leitch.