Sinai Hospital of Baltimore – Diabetes Medical Home Extender Program

Baltimore, MD
January 2018

Baltimore has approximately 620,000 residents, 63 percent of whom are African American, and 23 percent of whom live below the poverty line. Baltimore residents suffer from high rates of disease and unhealthy behaviors: 20 percent of African Americans in Baltimore report having an unmet medical need in the last 12 months; and 34 percent of residents are obese, with significantly higher rates among those with the lowest incomes. Community leaders have voiced their desire for health services to help them make better lifestyle choices. Sinai Hospital of Baltimore launched the Diabetes Medical Home Extender Program to help program participants learn to manage their diabetes and become active participants in their overall health.

The Diabetes Medical Home Extender Program offers home-based services by community health workers (CHWs) and a registered nurse to high-risk diabetic patients. The program breaks down barriers to primary and specialty care, educates clients about their diabetes, and makes referrals to available community resources. To participate in the program, patients must meet all of the following criteria: current admission to either Sinai Hospital or Northwest Hospital and at least one additional hospital admission or emergency department (ED) visit within the past 12months; a glucose reading of greater than 300 mg/dl or less than 40 mg/dl and/or HbAlC greater than 9 percent; and live within specific zip codes. All services are provided free of charge and target low-income, underserved persons.

Once a patient is identified as eligible, he or she is assigned to a CHW. The CHW visits the patient while he or she is in the hospital to explain the program and determine the patient’s interest. Once a patient expresses interest and intent to participate in the program, the CHW schedules a start-of-care visit within 72 hours of discharge from the hospital. The start-of-care visit includes the nurse and the CHW, who together conduct an initial assessment of the patient’s needs. Within 48 to 72 hours after the start-of-care visit, a debrief is held with the program supervisor, CHW and RN to discuss and plan for the patient’s needs. The patient is then seen weekly by the CHW and two additional times by the nurse. Patient progress is reviewed at 30 days, 90 days and 6 months after enrolling in the program. At 6 months the patient’s progress in the program is reviewed, and possible program completion is considered. If a patient is not ready for successful program completion, a continued service plan is made.

We track success of the program by comparing the number of inpatient admissions and ED visits for each client in the 90 days prior to entering the program and the 90 days after entering the program. In the most recently completed fiscal year, 84 clients were served. At least 53 percent of participants showed improvement on a clinical measure (e.g., decrease in A1C value over time during FY17). At least 32 percent of participants showed improvement on a behavioral measure (e.g., response change for “Taking Medications” from “Rarely” to “Most Times”) after beginning the DMHE program during FY17. Participants showed a 24 percent reduction in inpatient admissions and a 47 percent reduction in ED visits 90 days pre- and post- intervention during FY17.

Lessons Learned
Sinai Hospital has been refining its patient-centered continuum of care to address avoidable hospital utilization. This has been (and continues to be) accomplished by improving access to primary care and chronic health care clinics and segmenting the population by risk level to provide targeted care models and goals. Sinai and its parent organization, LifeBridge Health, recognize that care must be patient-centric, not hospital-centric.

Future Goals
As a result of the remarkable success of this program in its first four years, physicians at the Herman and Walter Samuelson Children’s Hospital at Sinai have expressed interest in replicating this program to assist pediatric chronic disease patients. The LifeBridge Health Department of Development is assisting with proposals for funding to begin this program. The program also has begun to expand its geography, to work with patients from Northwest Hospital, also within the LifeBridge Health system.

Contact: Mae Hinnant
Director, Grants Administration
Telephone: 410-601-4440


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