MAP H2H

1. MAP H2H The Maryland Access Point Hospital to Home Program

2. General Background • Grant program funded by the federal Balancing Incentive Program and Money Follows the Person initiative administered by the Maryland Department of Health • Seeks to develop a person-centered plan to meet the needs of those in transition from an acute setting to a stable supported environment in the community • Goal is to decrease recidivism of targeted hospital patients by providing access to community supports

3. Program Objectives • Strengthen ability to provide adequate community support and services • Reduce Medicare/Medicaid costs - supporting “Triple Aim” of health care: to reduce costs, improve the health of communities and improve the experience of care for patients. • Provide “warm hand-off” from acute hospital setting to community supports • Collaboratively develop services or enhance short term services, with partners, for newly discharged patients such as: • Chronic Disease Self-Management program • home delivered meals • in-home care • discharge transportation • minor home modifications. • Strengthen partnership between participating agencies and offices to increase the efficacy of service delivery in community setting.

4. Partners: the Interdisciplinary Care Coordination Team Members • Garrett County Community Action Committee (GCCAC), Aging and Nutrition (AAA), Maryland Access Point (MAP) • Garrett Regional Medical Center (GRMC) • Garrett County Health Department (GCHD) • Mountain Laurel Medical Group • Doctors’ offices in the county

5. Program Operation • MAP staff attends daily GRMC Interdisciplinary Discharge Planning meeting • Garrett Regional Medical Center (GRMC) staff identify potential patients that are over 60 and/or disabled that might benefit from the program • Maryland Access Point (MAP) staff sees targeted patients and/or family members, provides options counseling, outlines the primary community supports available and refers them for supports requested

6. Program Operation (continued) • MAP receives referrals from community health workers, Mountain Laurel Medical Group and other doctors’ offices in the county for community services. • MAP informs and links patients to community supports available through GC Community Action, Health Department and other resources/agencies needed to maintain optimal health and safety. • In conjunction with partners develop collaborative quarterly outreach/education to specific audiences (high ER users, newly disabled or caregivers) to further enhance positive community outcomes.

7. Performance Measures • Data collected by GRMC, MAP, and GCHD will be used to determine if the goal of decreasing recidivism is being achieved and that patients are satisfied with the services that are being received. • MAP follows up with patients to confirm success of referral • MAP conducts surveys at 14, 30, 60, and 90 days after discharge to collect data on subsequent admissions, including ER and doctor visits related to initial hospitalization • GRMC tracks LACE* scores of patients referred to the program

8. *The LACE Index The LACE index identifies patients that are at risk for readmission or death within thirty days of discharge. It is now widely accepted as a quality of care barometer. Hospital readmission rates have joined the ranks of mortality and complication rates in the world of “quality of care outcomes measures”. -from http://Besler.com/lace-risk-score/

9. Conclusion The MAP H2H Program’s primary goal is to connect seniors and/or persons with disabilities with adequate community supports to ensure their health and wellbeing. This grant provides opportunity for the Interdisciplinary Care Coordination Team to work together to identify, counsel, and coordinate services for a targeted population. The success of the program will be measured by readmission rates, reported satisfaction of patients residing in the community, and reduction of costs for patients and providers in alignment with “Triple Aim” goals.