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Spreading Innovations in Health Care Delivery

This website, endorsed by Maryland’s Stakeholder Innovation Group, offers a glimpse at how many of Maryland’s health care providers and community organizations are working together to improve care delivery.

We urge you to use this site to share innovative programs and practices that improve the health of Maryland’s communities.

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home grown

  • What are the objectives of the program?

    Reduced readmissions, Reduced spending

  • Please provide a brief description of the program:

    Medicare advantage program -

  • What is the primary source of funding for the program?

    Medicare A

  • Is this program operated as part of HSCRC's Care Redesign Amendment?


  • Which Center for Medicare and Medicaid Innovation (CMMI) category does (or would) the program fall under? Choose the best match.


  • What are the major components of the program?

    Care coordination/management, Protocols/agreements with care partners

  • What types of organizations participate in the program?

    Physicians office (primary care), Skilled nursing facility

  • Which population(s) does the program target?

    Medicare/older adults, Privately insured

  • How many patients have participated in the program to date?


  • In what Maryland jurisdictions do participating patients reside?


  • Briefly describe the staffing resources required to operate the program:

    Nurse Practitioner - RN

  • Briefly describe the key initial steps to implementation:

    we ask family / POA for permission for them to contact them and they make the calls and meet and explain the program

  • Are incentive payments to health care providers part of the program?


  • Which incentive type(s)?

    Bundled payments

  • Does the innovation program qualify as a CMS Advanced Alternative Payment Model (APM)?

    I dont know

  • What are/were the expected results in improved outcomes, population health, and cost savings?

    keep residents in house instead of going out to the hospital - treat signs and symptoms early - decrease cost of hospitalizations

  • 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:

    small enrollment - one resident out to hospital or on therapy case load, etc. eats at your cost and decreases your overall savings, Some of the expected results were achieved

  • Please briefly explain your answer to Question 27, and describe any cost savings results achieved to date:

    It seems we are doing the same care for those under pphp that we would do for those not enrolled in the program.