BWMC aims to cut readmission rates with transitional care facility

Christina Jedra
The BWMC transitional care facility will open in December.

University of Maryland Baltimore Washington Medical Center patients will soon have more help with post-discharge regimens and prescription instructions.

When patients are discharged from the hospital, it can be difficult to go from the support of full-time staff to relying on family for at-home care. Some struggle to manage complex prescription regimens. Other times, primary care doctors and hospital staff lack proper communication.

Starting in mid-December BWMC will offer new assistance to patients with the opening of the hospital's first transitional care center.

"It's important when they're discharged that the care doesn't stop from the hospital, that the transition from one level of care of another is smoother so they have better outcomes," said Dr. Christopher deBorja, who will head the new program.

The center, which will be housed in the Glen Burnie hospital, will have a team of about 10 including a physician, pharmacist, social worker, nurse, and nurse practitioner, as well as specialists on call. The hospital did not provide costs for the new center.

DeBorja, the chair of internal medicine at the hospital, said the goal is to have every patient transitioned to a primary care provider within 30 days.

"Our job will be to cushion their discharge so their transition to home is better and to link with community providers to continue to give them help," said deBorja.

The opening of the transitional care center will help lower the use of emergency resources by return patients, deBorja said, and reflects a state and national push toward reducing hospital readmission.

The state has programs tying readmission rates to revenue or penalties, according to the Health Services Cost Review Commission of the Maryland Department of Health and Mental Hygiene. The state rate of readmission from Jan. 2014 to Feb. 2015 was approximately 13 percent, a decrease of about 6 percent from the previous year, according to an Oct. 2015 report by Commission.

BWMC's rate of readmission is "worse than the national rate" of 15.2 percent, according to online government data. A specific number was not available.

Jennifer McAndrews — the director of operations for Synergy HomeCare, an in-home caregiving company serving the county — said she knows the necessity of transitional care firsthand: many of her clients are freshly released from a hospital.

"There are so many people that don't have the resources or family (to assist them) and fall through the cracks," she said. "It's important to have another set of hands... and a lot of people get better quicker in their own home."

Anne Arundel Medical Center uses a private contractor called The Coordinating Center to provide transitional care, said Pam Hinshaw, the director of case management at the hospital. Their caretakers connect patients with services, from finding a primary care provider and managing their medications to providing a at-home nurse, Hinshaw said.

AAMC's rate of readmission is no different than the national average, government data shows.

DeBorja said the transitional care model has proven effective across the country and that he has high hopes for the center at BWMC.

"At a hospital this size, we should expect at least a 20 percent reduction in readmission," he said. "(But) it could be much higher."

DeBorja said it's not yet clear how many patients will use the new center, but that BWMC would like to welcome patients from other institutions too.

"We want to see what our volume is," he said. "It depends on what the needs are."

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