Partnering to Reduce the Risk of Readmission | MedStar Health

Partnering to Reduce the Risk of Readmission

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Three african american family members pose for a photo.

Pictured above are Harry Woods (right) a patient of MedStar Good Samaritan, his wife, Sharron Woods (left), and his Meals on Wheels Care Manager (far left) at his home.

Empowering Self-Management

Studies show that following hospitalization, Medicare beneficiaries (people 65 years old and older) have a 20 percent chance of readmission within 30 days. MedStar Good Samaritan Hospital’s Empowering Self-Management program, a collaboration between the hospital’s Center for Successful Aging and Meals on Wheels of Central Maryland, aims to reduce this risk by providing supportive care to older patients after they leave the hospital.

During their stay in the hospital, older patients who are at high risk of readmission are offered an opportunity to participate in the Empowering Self-Management program for a 30-day or 60-day trial at no cost to the patient.

The services provided in this two-year pilot program include meal delivery, combined with a weekly check in from the Meals on Wheels team to help the patient and family members proactively look for any changes in health status and assess predictors of readmission. If representatives observe health concerns, such as changes in blood pressure or weight during these visits, they help the patient contact a nurse practitioner in the program to see what follow up might be needed to help avoid hospital readmission.

“Chronic disease management doesn’t happen in a doctor’s office—it happens where people live, breathe and work every day,” says Carolyn Ford, service line administrator at MedStar Good Samaritan’s Center for Successful Aging. “This program helps us get out into the community and extend the reach of the hospital into people’s day-to-day lives where they need additional support.”

When envisioning the program, George Hennawi, MD, the hospital’s division chief of Geriatric Medicine and director of the Center for Successful Aging, knew it was important to make a connection to the community.

“The most important part of how you manage a population is understanding the population in their own location,” Dr. Hennawi says. “By providing the right meals, information and support, the program gives physicians access to understanding patients’ social and environmental limitations to managing their diseases, such as their health literacy level or transportation availability.”


Now entering its second year, the Empowering Self-Management program has enrolled nearly 40 patients.

Harry Woods, 84, signed up for the program in 2017, following a hospital stay related to dementia. His physicians at MedStar Good Samaritan were able to monitor his transition through biweekly phone calls and home visits, while also improving his diet by providing him with two balanced meals a day.

Woods’ wife and primary caregiver, Sharron, said the depth and scope of support provided by the program has not only helped her husband transition back home safely, but has made his diabetes more manageable as well.

“The program has been more than helpful to my entire household, because I also care for my parents,” she remarked.

After seeing Harry complete the program with no additional hospitalizations and reduced medical, physical and social risk factors, Sharron decided to continue receiving home-delivered meals for him and started her parents on a meal delivery schedule as well.

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To learn more about MedStar Health's programs and initiatives across Maryland and the Washington, D.C., region that are contributing to healthier communities, contact Raquel Lamptey at 410-772-6910