Title: Shore Wellness Partners
Organization: Shore Health System/University of Maryland Medical System
Innovation types: Community Based Chronic Disease Management supported by Total Patient Revenue
Clinical Innovation: Patients with chronic diseases at high risk for readmission are referred (by hospital care-coordinators, MDs/RNs, community agencies, family members, etc.) into the Shore Wellness Partners community case management program. An advanced practice nurse or medical social worker conducts an in-home patient assessment and formulates an individualized plan of care. Other supportive services include medication management and education in self-management of their disease, assistance with arranging provider appointments and coordination of community resources that are available to meet the client’s needs.
An expansion to include laptops at home assessment for integration into EMR systems will be implemented at a later date.
Under the Total Patient Revenue program, Shore Health System receives a lump-sum payment from the state to care for the Medicare patients served at system hospitals, providing an incentive to keep patients healthy. Additionally, the future CMS withholding of reimbursement for readmissions within 30 days was another trigger for the program. The cost saving benefits both the hospital system and society as a whole if avoidable readmissions are decreased. The program is currently entirely by the health system.
Evaluation Type: Quasi-Experimental
Evaluation Plan: The organization plans to conduct an evaluation collecting data on patient utilization, diagnoses, and acuity of admissions before and after the intervention. There will also be provider and patient satisfaction assessments.
Patient Health and Cost Outcomes: Preliminary data on patient utilization, diagnoses, and acuity of admission before and after the intervention anticipated by late 2011.
Target Population: Patients with chronic diseases and frequent hospital admissions. Target of 140-175 patients based on current staffing. Currently, 77 patients are enrolled.
Date of Implentation: July 1st, 2011.
Contact: Sharon Stagg, firstname.lastname@example.org
Where to learn more: Please contact Sharon Stagg.