UMSJMC’s program partners community health workers with patients at high risk for readmission due to medical, psychological, functional and socioeconomic complexity. The community health workers focus on several issues with the patients, including transportation, housing and employment.
The program reduced readmissions among participants by more than 60 percent in its first 16 months.
“Readmissions aren’t the problem — they are the symptom. The real problem occurs when patients with complex medical issues and unmanaged psychological or social challenges don’t receive the support they need to maintain their health,” aid Mohan Suntha, MD, former UMSJMC president and CEO and current president and CEO of the University of Maryland Medical Center in Boston.
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