The path to lower readmissions lies in patient support, as an increasing number of hospitals and health systems are demonstrating. They build medical and social services that keep their most challenging populations from bouncing back to the emergency department or to an inpatient stay after discharge.

A case in point is Prince Frederick, Md.-based Calvert Health System, which has seen its readmissions rate nearly halved during the past three years. Hospital readmissions plummeted to one of the lowest in the state after the health system launched “Calvert Cares,” several community-level initiatives that strengthen ties to physicians, urgent care centers, diagnostic centers, the county health department, skilled nursing facilities and other health care organizations in a tri-county area of the state.

“A bridge to wellness” is how Karen Twigg, the health system’s director of care coordination and integration, describes Calvert Cares. “The program goes where health care ultimately needs to go, and that is in the direction of population wellness,” she says.

The program helps struggling inpatients comply with follow-up care once they are home. It helps patients pay for medications, medical supplies or transportation to medical appointments. Services include a patient portal that offers patients secure internet access to their hospital medical record and services, and mental health and substance abuse counseling.

A physician, nurse, social worker and pharmacist see patients at two discharge care clinics – piggybacked onto the health system’s urgent care clinics – for managing patients who have complicated discharge care plans and multiple medications that need adjusting. The second clinic opened earlier this month.

The clinics see patients who are likely to leave the hospital only to return days or weeks later. Those patients are typically elderly and suffer from chronic diseases that account for most of health care spending. The patient spends an hour with each member of the care team. Then there is a follow-up visit at home by the social worker and pharmacist who make sure the patients are able to manage their illness.

Staff survey every patient seen in the clinic to gain immediate feedback, address needs and identify gaps in service. According to survey findings,  97% of patients know when, how and why to take their medications, 94% know what they need to do between the clinic visit and their next medical appointment, and 92% are better prepared to follow their treatment plan.

Calvert Cares’ post-discharge clinic saw 165 patients last year. Less than 4% of them returned to the hospital within 30 days of discharge.

“It is not about patient engagement,” Twigg says. “It is about patient empowerment.”

Calvert County has a number of nonprofit agencies and organizations that address a range of community health needs, says Twigg. What was lacking was a “structured network for meaningful collaboration” between Calvert Health System and other providers and agencies, she says. In 2014, the health system helped form a coalition of more than 30 community groups to improve patients’ transition from hospital to post-acute care. It serves as a backbone to Calvert Cares. 

“Calvert Cares is an investment in our patients and our community,” Twigg says. Reducing readmissions is one indicator of success. “But the real return on our investment is in the improved outcomes of our patients’ health.”