Clinical Care Transformation

Clinical Care Transformation Overview

Medstar’s Clinical Care Transformation is a collaborative team of doctors, nurses, and other healthcare specialists that offer you services and programs to keep you healthy and able to do the things that matter to you. We are “wrapping our arms” around you and your family to be sure you receive the right care by the right provider in the right location when and how you need it.

Whether you need a primary care provider, a provider that specializes in diabetes, the heart, behavioral health, elder care, home care services or palliative care, we are ready to support your needs.

We will advocate for you, our patients and communities, to ensure your time and dollars are spent wisely in high quality services and programs that are important to you. That means Better Care for Healthier Populations through Smarter Spending of our healthcare dollars. Get to know our programs and partners!

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To request more information about an individual program, please contact us. 

Programs and Partners

Case Management

Case management services are offered to patients and families during the hospital stay. These professionals work with you and your family to be sure you understand your illness and will help you overcome barriers to achieving your healthcare goals. Case Managers ensure the entire care team know what your healthcare goals are and work to be sure you receive the services you need during your hospital stay and after discharge.

Community Health Advocates

Community Health Advocates are community-based non-clinical team members that can help you with things like housing, transportation, food, support groups, and help navigating the healthcare system. Learn more by reading our PDF.

Community Health Classes

We care about the health and wellness of every member of our community. That’s why we provide a variety of free and low-cost classes and programs in our hospitals on an ongoing basis. Programs cover a wide range of topics ranging from chronic disease prevention and management for heart disease, stroke, cancer, diabetes, and obesity; to mental health support; prenatal wellness to support groups; to smoking cessation classes; and more. View a list of classes offered and details about each one here.

Maryland Primary Care Program (MDPCP)

This primary care transformation program funded by the State of Maryland is designed for Medicare Beneficiaries living in Maryland and utilizes a wide range of care coordination services to promote health and wellness, including disease management, help with medications, nutrition counseling, behavioral health, and linkages to social services. Our MedStar Health program spans 50 practices and over 40,000 beneficiaries in Maryland.

MedStar Family Choice

MedStar Family Choice is a Managed Care Organization serving Medicaid in the state of Maryland. The MedStar Family Choice team also consists of nurses and social workers ready to help you coordinate your care. Members have access to a wide range of services including: transportation, dental, vision, pharmacy, health education, immunizations, wellness screenings and 24/7 virtual visits to keep you healthy. Visit the MedStar Family Choice website to learn more.

MedStar Diabetes Institute

Our Diabetes "Boot Camp” is a personalized 12-week diabetes care management program for adults living with diabetes which is challenging to self-manage. Diabetes education and support as well as timely diabetes medications management are provided either entirely by our remote clinic or by a combination of one or two in-person visits followed by remote visits.  Learn more here.

Senior Services

Many elders struggle with disability and severe chronic illness, and often have a hard time getting to the doctor’s office. As a result, health status may suffer and lead to unnecessary visits to the emergency department, hospitalization or nursing home care. We have a home-based primary care program (House Call Program) that offers medical and social services to you in your home from a team of expert geriatricians, nurse practitioners, and social workers. We also provide inpatient geriatric care at MedStar Washington Hospital Center. Our social work team links patients and families to community resources, provides case management through DC Elderly & Persons with Disability Medicaid waiver program, and supports caregivers through various weekly and monthly activities.

Palliative Care

Our palliative care team members are experts in this specialized field of medicine—and deliver an important level of additional support to our patients. The team takes a holistic approach to care aimed at healing mind, body and spirit. Members of the team work collaboratively with one another, and hand-in-hand with patients’ other medical specialists and health care providers to help ease physical pain and other symptoms and promote patients’ emotional, psycho-social and spiritual health at any stage of illness.

MedStar Visiting Nurse Association

Visiting Nurses provide healthcare services in a patient's home. Home Care is prescribed by your doctor to provide addition support when there is a recent discharge from a hospital or long-term care facility, such as a nursing home or rehabilitation center and or a need for nursing or therapy at home.

Home health care helps patients get better to become as independent and able to manage life at home. For those with long-term health problems, the goal is to maintain the highest level of ability and learn to live with an illness or disability. Home healthcare services generally include skilled nursing, rehabilitation and assistance with the activities of daily living. The service must be ordered by the patient's doctor and be covered by insurance. For more information visit the MedStar Visiting Nurse Association's website.

Behavioral Health

Our experts offer evaluations, medication management as well as individual, family and group therapy in locations across the Washington, DC and Baltimore regions. Services include: child and teen psychiatry, additions and mental care, and care for neuropsychiatric illnesses. Learn more about behavioral health here.

Peer Recovery Coaches

Provide patients who have sought treatment for alcohol or drug dependency and addiction issues with the emotional support needed to move toward recovery. These coaches, most of whom have personal experience with substance use, assist in connecting patients to treatment services, including support groups, inpatient, and outpatient treatment programs. Read more here.

Congestive Heart Failure/Advanced Heart Failure Management

Our team of diverse specialists helps enhance your quality of life while living with advanced heart failure. We offer: individualized support, family support, education and symptom management by a team of social workers, nutritionists, exercise specialists and financial counselors. Learn more about heart failure from the MedStar Heart and Vascular Association here.

Clinical Care Transformation Team

Meena Seshamani MD, PhD
Vice President

Julie Beecher MS, M.P.H.
Assistant Vice President

Jeanne DeCosmo BSN, MBA
Senior Director

Armando Nahum
Patient and Family Advocate
Director, Center for Engaging Patients as Partners MIQS

Paula Sessoms
Executive Assistant

For More Information about our Primary Care and Program Partners

If you are interested in joining our primary care practices or want more information about our programs please fill out the information below. We will be in touch with you shortly.