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Community Care Team

The Community Care Team works with patients and their health care providers to improve patient health conditions after their hospital stay. Specifically, the team helps ensure patients have a smooth transition from hospital to home, learn to manage their illness and feel confident in doing so on their own. The team has won numerous awards for outstanding service, including a citation from Governor Hogan, the Daily Record Health Care Hero, Baltimore Magazine Top 50 Nurses, and the JHU School of Nursing Rising Star award.

Our Community Care Team is a comprehensive support system that includes a Community Health Worker, Community Health Nurse and Community Social Worker that are trained, certified and experienced.

The Community Health Worker supports lifestyle and community service needs, such as:

  • Arranging for transportation to appointments
  • Establishing food, financial and housing assistance
  • Coordinating home health care workers
  • Accessing senior programs
  • Helping with proper diet management

The Community Health Nurse supports the physical health of patients, including assessing their health during their first home visit, organizing their medication list, providing information to their health care providers and monitoring their progress.

Some patients may need additional emotional support after their hospital stay. The Community Social Worker supports their mental health well being by assessing their anxiety symptoms, providing informal counseling and making referrals to behavioral health providers.

Learn more about the Community Care Team:

  • Within days of leaving the hospital, a Community Health Nurse and a Community Health Worker visits you at home to assess your physical health and lifestyle and provides you with connections to community resources based on your needs.

    Our team then arranges for you to meet with your primary care provider. If you do not have a provider, our team can help you find one. Our team then work with you and your provider to identify goals and a health action plan that supports your health and fits your lifestyle.

    Our team also arranges times to meet with you on a regular basis to help you reach your goals. These appointments may involve meeting with a team member as frequently as once a week. Follow up can occur on the phone, at home or at the doctor’s office.

    You can anticipate working with our team for 30 to 90 days, depending on your needs. When you have reached your health goal(s), our team works with your primary care provider to make sure you continue receiving the help and support you need.


    • Works with you and your medical team to set goals for your health
    • Acts as your personal health care advocate
    • Ensures you have a smoother hospital to home transition
    • Connects you with community resources
    • Facilitates your health care activities, including making appointments
    • Coordinates with your primary care provider and specialists
    • Clarifies prescribed medications and how and when to take them
    • Delivers these benefits and more for free


    To receive assistance from our Community Care Team, you must meet the following:

    • Be an adult Medicare beneficiary
    • Have had two or more encounters with the hospital in the last 12 months, including observation, inpatient and emergency room visits
    • Live in Howard County
  • The Community Care Team assists patients with …

    • Solving personal issues that interfere with medical compliance
    • Providing medication-reconciliation
    • Instructing chronic disease management and disease-specific education
    • Connecting to community health resources, including primary care, specialist providers and social service agencies

    Our efforts have resulted in ...

    • Reduced hospital readmission rates at seven, 30 and 60 days post patient discharge
    • Service satisfaction ratings raging from moderate to very satisfied from 100 percent of patients
    • Patients reporting greater access to quality health care

    The Team Approach

    Our team of nurses and health professionals work with you and your patients to ensure their hospital to home transition is a smooth process. Our approach teaches patients how to effectively manage their chronic conditions.

    Together we can:

    • Improve health behaviors and outcomes
    • Increase treatment plan compliance
    • Decrease preventable hospitalizations
    • Reduce high costs of care
    • Address any social barriers

    Hospital-to-Home Transition
    Within days of your patient leaving the hospital, a Community Health Nurse and a Community Health Worker visit the patient at home to assess their physical health, lifestyle and community resource needs.

    Our team then meets with your patient to identify goals and create a health action plan that supports their health and fits their lifestyle. Our team then relays the plan to you for your approval.

    In the Program
    Patients, who qualify to enroll, work with our team for thirty to ninety days depending on their health action plan. During this time, our team regularly meets with your patient and is also available as a resource to you and your staff.

    Our goal is for your patients to improve their health and feel connected to their doctors and community services.

    Eligibility Criteria

    Patients must meet the following conditions:

    • Medicare beneficiary
    • Two or more encounters with the hospital in the last 12 months, including observation, inpatient and emergency room visits
    • Howard County resident
  • Howard County General Hospital offers training and certification for those interested in becoming a Community Health Worker (CHW).  Learn more >>

Contact Us

[email protected]
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