Chronic Care Management Program Team
Frederick Memorial Hospital
Frederick Memorial Hospital's Chronic Care Management Program Team is led by Lisa Hogan and relies upon the dedication of nurses, Kim McCormick, Chris Kieti, Tiffany Rupp, and Angela Kombo. The CCMP Team monitors patients daily, conducts weekly check-in calls, and provides home visits to high-risk patients when the need arises. The success of Frederick Memorial Hospital (FMH) and their CCMP relies on the exceptional teamwork and communication if its clinical team.
The CCMP Team is committed to engaging and educating patients. To do so, the CCMP team creates individualized care plans and goals for each patient utilizing the telehealth platform. Celebrating goals achieved and milestones reached reinforces this individualized care and reinforces patients' positive outcomes.
Due to the success of the CCMP team, FMH's CCMP has become known within the hospital and the larger community as a beacon for healthcare innovation and patient care, specifically disease management for high-risk patients.
FMH began their partnership with HRS as a pilot program in late 2016, serving 25-30 patients. As of 2019, the CCMP serves an average of 225 patients per month. By using telehealth and the personalized care plans developed by the CCMP clinicians, the team has reduced FMH's 30-day readmission rate by 84% and ED utilization by 52%. The overall cost savings to Frederick Memorial Hospital was $2.1 million in 2018.
Along with the marked improvement in clinical outcomes and reduced costs, the CCMP and the CCMP Team have helped patients become more engaged in their care plan and more secure in their homes.