Helping to Reduce Readmissions in Baltimore, MD

GoMo Health has launched the first of its kind 30-60-90 Day Readmission Reduction program, called HealthLink, in the Baltimore, Maryland area. Together with Saint Agnes Hospital and Health Care Access Maryland, the program helps patients who have recently been discharged from the hospital for chronic conditions including Diabetes, COPD, Congestive Heart Failure (CHF), Hypertension and Chronic Kidney Disease (CKD).

Saint Agnes Hospital is a Baltimore nonprofit teaching hospital, and Health Care Access Maryland is a nonprofit agency that connects Maryland residents to public health care coverage and helps them navigate services effectively.

Here’s how it works:

1. The cloud-based Concierge Care® platform enables Discharge Nurses to onboard patients at point of discharge, using a customized cloud-based Health Risk Assessment (HRA) survey.
2. The survey identifies the patient’s procedure or chronic condition, captures personalized engagement preferences (such as language and family care givers), and risk stratifies patients based medical and lifestyle conditions.
3. Once enrolled in the program, discharged patients and their support community begin to receive educational Care Messages™ (via SMS or email) with information and videos about managing their recuperation, local health care resources and reminders for medication, Rx refills, follow-up visits and condition-specific testing.
4. The program further provides click-to-call links to a 24/7 Nurse Call Hotline for real-time live triage and a secure, HIPAA compliant 2-way text chat function that facilitates Case Manager to Patient digital conversations.

To learn more about HealthLink, click here.