Chair Files

Mapping a Course for Change

Making incremental changes and collaborating with area hospitals and community organizations have been a winning combination for improving care coordination and reducing readmissions at Bon Secours Baltimore Health System. The health system serves a West Baltimore population with 20% of families living below the poverty line. Rates for diabetes and COPD are two to three times higher than state averages; asthma rates are five times higher. Emergency department visits are about 12% higher than the state average. To improve patient outcomes, the health system focused on “mapping the course for change,” implementing initiatives every few months. For example, in 2012, the health system started a case management program in its emergency department and implemented follow-up appointment scheduling. In December 2012, Bon Secours became part of the West Baltimore Readmissions Reduction Collaborative, a community-based care transition program that targets Medicare participants who are at high risk of hospital readmission. Two other Baltimore hospitals and two community organizations, including The Coordinating Center, make up the collaborative. In 2013, the health system began using a high-risk assessment tool, established its NeighborCare bedside delivery program and created an in-house care transition team. As a result of these and other initiatives, Bon Secours Baltimore reduced readmissions from 15.5% in 2011 to 10.8% in 2013. Core measure readmissions for AMI, HF and COPD decreased from 0.90 to 0.59. The health system continues to develop “nontraditional pathways” to provide excellent patient care.
For more information about these initiatives, contact Afryea Brown, director of outcomes management and social work, at has additional case studies and information on care coordination and reducing readmissions from AHA resources and other groups.


Additional Resources

Webinars December 13th, 2017

Equity of Care Webinar SeriesPart 2: Aligning Diversity and Inclusion, Community Engagement, Busi......

Webinars November 20th, 2017

Equity of Care Webinar SeriesPart 1: Aligning Diversity and Inclusion, Community Engagement, Busi......

Webinars November 17th, 2017

Transportation and the Role of Hospitals This AHA webinar on “Transportation and the Role of Hos......