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Community Care Team: Information for Health Care Providers

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
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