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What are the objectives of the program?
Improved care coordination, Improved health outcomes, Reductions in health disparities, Reduced readmissions, Increased use of preventive and primary care, Reduced avoidable utilization
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Please provide a brief description of the program:
Mobile integrated program between hospital, health department, and City of Salisbury. Target population is EMS high-utilizers. Nurse practitioners and EMT provide initial in-home assessment, obtain consent, and develop care plan. Patient followed by RN and EMT until sufficient progress named, the transitions patient to a CHW through warm handoff.
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Is this program operated as part of HSCRC's Care Redesign Amendment?
No
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Which Center for Medicare and Medicaid Innovation (CMMI) category does (or would) the program fall under? Choose the best match.
Initiatives_Focused_on_the_Medicare_Medicaid_Enrollees
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What are the major components of the program?
Care coordination/management, Patient assessment tools, Patient education/coaching/self-management, Multidisciplinary care teams, Patient care plans, Community health workers, Interventions to address social determinants of health, Protocols/agreements with care partners, CRISP tools (e.g., Encounter Notification Service)
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What types of organizations participate in the program?
Hospital/health system, Non-clinical setting
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Which population(s) does the program target?
Medicare/older adults, Medicaid, Dual eligibles (Medicare-Medicaid enrollees), Privately insured, Individuals with multiple chronic conditions, Frail/disabled, Younger adults
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How many patients have participated in the program to date?
30
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In what Maryland jurisdictions do participating patients reside?
Wicomico
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Briefly describe the staffing resources required to operate the program:
NP, RN, EMT
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Briefly describe the key initial steps to implementation:
Grant funding received; MOU signed; process developed
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Are incentive payments to health care providers part of the program?
False
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What are/were the expected results in improved outcomes, population health, and cost savings?
Reduction in EMS calls for target population.
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Have expected results for improving outcomes and population health been met?
Yes, expected results were achieved
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Please briefly explain your answer to Question 25, and describe any results for improved population health achieved to date:
There has been an approximate 34% reduction in EMS calls among the group., Yes, expected results were achieved
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Please briefly explain your answer to Question 27, and describe any cost savings results achieved to date:
Cost savings have been realized through reduction in dispatched emergency vehicles, emergency transports, ED visits.