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Montgomery County, Maryland
In a first-of-its kind project, Connected Health Resources (CHR) and Datuit are working with a residence for low-income seniors and disabled individuals in Maryland. Patients with multiple health issues and their family caregivers are presented with an informational website and personal health application to help manage their own care while living independently. A clinical pharmacist utilizes data from Surescripts to reconcile medication information from multiple providers, as well as generate a schedule and medication instructions in a variety of languages utilizing embedded technology from Polyglot. Patients and families select a range of healthcare and social services from the community utilizing the Community Resource Finder. This is the first shared platform where health and social services providers, patients and family caregivers all contribute information to support the patient’s health goals. It is also the first pilot to use Surescripts data via the Maryland HIE to support medication therapy management.
The Community Health Gateway delivers plain-language and multilingual tools and resources to patients and family caregivers that allows them to more easily maintain and improve their health after returning home from the hospital or other facility. The Gateway does this by integrating healthcare resources, social services and community supports, resulting in better communication among all those caring for the patient and improved patient outcomes. Patients and family caregivers are armed with Gateway tools that put them in a position of vital partners in transforming healthcare.
An estimated one in three patients have difficulty understanding their medication instructions. By knowing their medication schedule and better understanding their medical conditions, patients and family caregivers are able to take meaningful steps to more conveniently manage their health. Accessing easy-to-understand health information is critical in this process, and medication errors can be reduced when patients understand their medication instructions. In addition, family caregivers who have limited awareness of community resources can use the Gateway to access comprehensive information on local resources.
The Gateway also assists clinicians and care coordinators in communicating this critical information to patients and families as care partners, thereby improving post-hospital recovery, reducing emergency department (ED) use and institutional care and promoting patient and family engagement. Over time the Gateway will help facilitate true patient-centered care. We expect to find reduced healthcare costs and improved quality of life in a high risk population when this type of collaboration is facilitated.