Shore Regional Medical Center's Population Health Team Makes Strides in Chronic Disease Management
The University of Maryland Shore Regional Health System Population Health Team has made progress over the past year. The team helps residents with chronic conditions manage their conditions at home and improve their health by working with local health care providers, community organizations, government agencies and others.
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The University of Maryland Shore Regional Medical Center's Population Health team has made impressive strides over the past year, helping residents in five counties manage chronic conditions so they can thrive at home.
Highlights of their work include
COMMUNITY CASE MANAGEMENT: The Seacoast Community Outreach Team (SCOT) recruited 115 patients in Kent County to provide home visits and coaching. After six months, High Utilization patients reduced their healthcare costs by an average of $5,919 each.
Medication Management: Transitional Care pharmacists provided more than 500 consultations and responded to 1,200 medication reminders at 10 senior centers in the region.
Transitional Nurse Navigators (TNN): Through phone calls and home visits, Transitional Care Navigators reached more than 20,000 patients and resolved 3,500 alerts (75% within three days). They also enrolled 649 patients in heart failure, COPD and diabetes support programs.
Heart Failure and Diabetes Continuing Care Program: 182 patients enrolled in the Heart Failure Continuing Care Program received coordinated care with acute care, cardiac rehab, and TNN follow-up. diabetic patients with high HbA1c received education and referrals, and their HbA1c dropped an average of 10 percent after six months.
Health Equity: The Population Health Program eliminates health disparities through on-site screenings and education in the workplace and African American community.
Advance Directives: By partnering with senior organizations, more than 1,000 individuals have completed advance medical directives and placed them in their medical records.
Overall, the Population Health team's collaborative approach focusing on home care, community engagement, and medication management has dramatically improved the health and well-being of residents throughout the region.
