Calvert Memorial Hospital - Calvert CARES

Overview

In January 2015, the Calvert CARES program was developed to bridge the gap between community resources and patient health care needs/self-management capabilities. This program incorporated initiatives begun in 2012 with new concepts developed over the past three years, to broaden the program’s ability to meet community needs through a patient-centered, fiscally accountable model. The philosophy behind Calvert CARES is simple: knock down barriers and build bridges to care, listen actively and often to patients, know what agencies and organizations exist in the community and create a forum for them to flourish, and promote patient engagement to empower them toward a healthier lifestyle and improved health care management. This has been accomplished through no-fee services provided by the hospital’s Transitions to Home Team (physician, nurse, pharmacist, social worker), in collaboration with local health care coalition membership. Through Calvert Memorial’s Medication and Transportation Assistance Programs (MAP/TAP), Discharge CARE Clinic and collaboration with the Calvert County Health Department (Project Phoenix – grant-funded behavioral health support), the program has had a significant impact on patients’ health care management and outcomes.

Impact

In the first half of FY 2016, there were more than 400 referrals to the program. The majority of those patients received one or more coaching phone calls, 26 patients received an average of $90 in assistance through MAP and TAP, and 83 patients were connected with a primary care physician. Approximately 10 patients per month received visits from the Transitions to Home Team, and nearly 100 patients were seen in the Discharge CARE Clinic (average of 3 care hours per clinic visit). Only 23 of these 400+ patients returned to the hospital within 30 days of their referral (5.75 percent). When compared with the goal and results, the positive impact of this program is clearly evident. Goal: Less than 9 percent of patients admitted inpatient will be readmitted to any hospital within 30 days of their initial discharge.

Lessons Learned

Program leaders sought input from patients as they have developed and implemented the program, identifying early on that program success would hinge on not duplicating what was occurring in other clinical settings. They slowed down the pace to give patients time to listen, process and formulate questions, focusing on identifying the patient’s goal(s) and building their plan upon them. They looked at the patient fresh each time, as they never knew when the patient would be ready to make needed lifestyle changes. They developed tools to fit patients’ needs, not the program needs or what they thought patients needed. Most importantly, program leaders identified that it’s all about their relationship with their patient. Consistency + Collaboration + Communication = TRUST.

Future Goals

Plans are to offer program services at a second location in 2017, based upon disparity needs identified in a 2014 Community Health Assessment. This will require adding clinical staff and equipping another clinic site.

Contact: Susan Dohony
Vice President/Chief Quality Officer
Telephone: 410-535-8150
Email: sdohony@cmhlink.org