-
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, Reduced spending
-
Please provide a brief description of the program:
Population health initiatives promoting care beyond the walls of the hospital.
-
Is this program operated as part of HSCRC's Care Redesign Amendment?
No
-
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
-
What are the major components of the program?
Care coordination/management, Patient assessment tools, Care transitions, 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, Risk stratification, CRISP tools (e.g., Encounter Notification Service)
-
What types of organizations participate in the program?
Physicians office (primary care), Hospital/health system, Skilled nursing facility, Home health care, Rehabilitation center, Hospice, Behavioral health provider (e.g., mental health and/or substance abuse)
-
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
-
How many patients have participated in the program to date?
approx 5000 +
-
In what Maryland jurisdictions do participating patients reside?
Anne Arundel, Baltimore, Baltimore City, Howard
-
Briefly describe the staffing resources required to operate the program:
Transitional Nurse Navigators; SNF liaison; Behavioral Health High Risk Care Coordinator; Care Managers; Social Workers; Discharge Clinic staff
-
Briefly describe the key initial steps to implementation:
Started with SNF & homecare readmission root cause analysis monthly meetings with vendors; next step was the BATP grant growing initiatives into community care management programs; support for community PCP & Behavioral Health offices; worked with CRISP & IT to build tools within the EHR
-
Are incentive payments to health care providers part of the program?
False
-
What are/were the expected results in improved outcomes, population health, and cost savings?
decrease utilization, PQI, readmissions, total cost of care. Increased utilization of community programs/resources
-
Have expected results for improving outcomes and population health been met?
Some of the expected results were achieved
-
Please briefly explain your answer to Question 25, and describe any results for improved population health achieved to date:
this is an ongoing initiative showing early positive results with pre/post reports; continuing to grow the program improvement increasing patient & community provider engagement, Some of the expected results were achieved
-
Please briefly explain your answer to Question 27, and describe any cost savings results achieved to date:
CRISP pre/post data shows favorable cost savings