Care Coordination serves as a single access point for hospitals and community providers to connect, communicate, and collaborate. This program addresses one of the most pressing challenges facing Maryland's health and human services system: reducing preventable hospital readmissions.
The program also:
- reduces the administrative burden that hospitals experience during the discharge process
- reduces emergency department overstays
- connects patients to community supports
We work with behavioral health patients who need inpatient and outpatient behavioral health care, and recently completed a 1-year pilot program for Medicaid- and Medicare-eligible older adults and adults with disabilities.
It's making a difference for patients and hospitals. Our pilot program resulted in over $1.5 million in net savings within 120 days.
Coordinated Care
From complex to routine cases, Maryland hospitals can leverage our technology and infrastructure to coordinate, monitor, and track cases.
With a large network of participating hospitals and state and local agencies, we facilitate care coordination across systems, involving representatives from health and human services agencies, as well as schools.
Our comprehensive network of community support, infrastructure, and data-sharing capabilities can enhance dignity and independence for patients, while also saving hospitals money.
How We Help Hospitals
We can help hospitals improve patient care by reducing hospital overstays and readmissions.
Care Coordination Case Studies
Learn how the program is changing patient lives.
Behavioral Health Program
Adolescents aged 13-17 years are referred most to the Behavioral Health Care Coordination program. 65% of patients referred are under age 21.
Care Coordinator, Kia Greene, talks about one of those cases where she helped a youth get discharged from the hospital after 100 days.
Hospital Transitions Program (HTP) Pilot
This 1-year pilot program, sponsored by the Maryland Department of Aging (MDoA) and the University of Maryland School of Medicine, focused on older adults and adults with disabilities who are dually eligible for Medicaid and Medicare.
These patients received intensive, person-centered support that lasted for 120 days after hospital discharge. Care Coordinators guided patients through waiver enrollment, paperwork, insurance navigation, and access to essential services.
One Patient's Story
"In just a few months, my client moved from daily risk and dependence to stability, income, and renewed dignity. My client’s success proves the impact targeted support can have to break the cycle of hospital readmission and transform lives."
– Care Coordinator, Hospital Transitions Program
The Care Coordinator helped solve numerous challenges, including an unsafe home environment, untreated chronic wounds, and an inability to eat without dentures. The Care Coordinator advocated, connected, and supported the client in obtaining grab bars for their home, wound care, dentures, and even employment!
2025 HTP Impact
$1.6M+
Total Avoided Charges
(120 days)
$1.5M+
Net Savings
(120 days)
22:1
Return on Investment
2025 Behavioral Health Impact
Strong Partnerships Support Patients
We continue to expand and deepen our partnerships with a diverse network of hospitals and community providers.
As we strengthen partnerships, we align systems, enhance collaboration, and streamline care in the often fragmented health and human services ecosystem.