Care Coordination

Improving Care for High Utilizers: The Max Method

Over the past three years, almost 80 hospital-based teams across New York State have implemented the "MAX Method" to improve care for high utilizers. The MAX Method has been implemented by hospitals from the Adirondacks to Staten Island and everywhere in between - it is broadly applicable, locally adaptable, and effective! We are hosting Amy Boutwell, MD, MPP, the developer of the MAX Method for a two-part webinar series describing the core concepts and key operational aspects of the MAX Method and the impact it has on patients, teams, cross-setting partnerships, and outcomes. 

June 13  June 27 
Slide Presentation

Slide Presentation


Care Alert Sprint Collaborative

A critical step in securing a full fiscal year update in January is to demonstrate to the Health Services Cost Review Commission your use of “care alerts” by uploading them to the Chesapeake Regional Information System for Our Patients (CRISP). To help you do that, CRISP and MHA are introducing what we’re calling the “Care Alert Sprint,” a six-month initiative to help you get the job done using existing personnel and resources – meeting you where you are, so to speak.

Care alerts are brief, to-the-point messages shared among clinicians to help determine the main driver of utilization for specific patients, support care coordination, and inform the appropriate course of treatment, including a decision whether to admit. Several hospitals are already creating and sharing care alerts internally, and others have begun to share them more broadly, including across different hospitals and ambulatory settings.

The Care Alert Sprint is aimed at your population health, readmissions reduction and emergency department leads. To guide our initiative we have engaged Dr. Amy Boutwell, a national expert on readmissions reduction whose work with hospitals across the country, including in Maryland, promises to be a valuable boost to our efforts. A key part of the sprint will be your hospital teams sharing what works and what doesn’t in getting the care alerts uploaded quickly and efficiently.

Visit our Care Alert Sprint page for more details.

Handle with Care
The Maryland Hospital Association is working with partner organizations and with cross-continuum teams to reduce avoidable readmissions within Maryland and improve care transitions for patients and families.


What They Are
"Readmission" occurs when patients who have had a recent stay in the hospital go back into a hospital again. Patients may have been readmitted back to the same hospital or to a different hospital or acute care facility. They may have been readmitted for the same condition as their recent hospital stay, or for a different reason. Often referred to as "rehospitalization." 

Who's At Risk
Patients in transition — those moving from one care setting to another — are at increased risk for hospital readmission. Unanswered questions can increase patient risk for readmission, such as: Who is in charge of the patient transition?; What is the plan?; Is the plan and follow-up instructions understood?’, and Does the patient know who to call with questions once he/she is home or in their new care setting? 

What's At Stake
Patients move from one setting of care to another, or to one set of care providers to another during an episode of illness. As patients and families navigate across new care settings and among different care providers, they often encounter communication challenges and confusion around who is clearly accountable for their care. This can lead to medical errors, duplication, increased costs, and may also lead to higher rates of hospitalization. 

What Providers Are Doing To Prevent Readmissions
Below are several links with further details surrounding work being done on readmissions.

HCAHPS Patient Safety Learning Network
Community-based Care Transition Grant Awarded to Maryland Partners
Health Enterprise Zones

Find a Cross-Continuum Partner

Maryland Access Point (MAP) 
Search for long-term support information and services throughout Maryland.

Maryland Consumer Guide to Long Term Care 
This guide contains information about planning for long term care needs; community support services; resources for family caregivers, transportation, and technology assistance for seniors and people with disabilities