title: Unique program aims to connect frequent ED utilizers with medical homes, resources to meet complex needs.
abstract: Sinai Hospital of Baltimore in Baltimore, MD, is partnering with HealthCare Access Maryland, a non-profit organization in the state, to link patients who frequent the ED for care with medical homes and other resources that can better meet their medical and social needs. Under the Access Health Program, ED-based care coordinators intervene with patients who meet program criteria, linking them with medical homes and other resources that address their complex needs. The hospital has devised a flag to notify the ED when a frequent-utilizing patient presents in the department for care. Care coordinators then meet with these patients and get their consent to participate in the program. Within a week of the ED visit, care coordinators schedule a home visit with the patient to establish a care plan containing specific goals and a time frame to carry out these goals. Patients remain in the program for 90 days as care coordinators work to hand them off to longer-term resources. Many of the patients enrolled in the program have substance abuse and mental health problems. Patients are also often uninsured and/or homeless. Within two months of launching the program, care coordinators enrolled 74 patients, with the goal of eventually bringing that number to 200.
mesh_terms: D015142:Baltimore; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D006301:Health Services Needs and Demand; D006801:Humans; D019982:Organizational Case Studies; D018802:Patient-Centered Care; D016730:Program Development / Q000379:methods; D014481:United States