Maryland's All-Payer Hospital System Modernization

Care Coordination Workgroup

Care Coordination Final Report

The purpose of this Workgroup is to facilitate multi-stakeholder discussions regarding efficient and effective implementation of population-based and patient-centered Care Coordination to support the new Maryland All-Payer Model that began on January 1, 2014. The HSCRC’s focus on Care Coordination is based on the consensus that was achieved through the Advisory Council and multiple workgroups that this should be top a top priority, including the potential for shared infrastructure and common approaches.

Care Coordination Workgroup Membership

The Health Services Cost Review Commission (HSCRC) has appointed the a diverse group of individuals to serve on the Care Coordination Workgroup. The list of workgroup members is available at the following link:

Care Coordination Workgroup Appointments

Meeting Schedule, Goals, and Documents

The Physician Alignment & Engagement Workgroup schedule is provided in the table below. Additional meetings will be added to the schedule. Please check back for the location and schedule of future meetings. Questions related to the schedule and location of meetings should be directed to:

Meetings - 2014

Dates and Location Meeting Goals Meeting Documents
November 17, 2014

3 – 4:30 pm

4160 Patterson Ave.
Baltimore, MD 21215

Workgroup Kickoff Meeting
  1. Intros, Overview of Charge & Outline Schedule of Work

  2. Work to Date , including synthesis of Care Management paper done by HMA for the HSCRC, and Care Coordination highlights from Data & Infrastructure and Alignment & Engagement Workgroups

  3. Frame Key Issues and Decision Points related to Care Coordination

  4. What is a realistic timeline for Care Coordination implementation? We need balance between getting started quickly and the longerterm need for infrastructure (CRISP initiatives, workforce development, building provider collaborations). What are the potential barriers and ways to address them?
  1. Work Plan

  2. Final Charge to Workgroup

  3. Webinar Recording

December 12, 2014 

1 – 5 pm

Maryland Hospital Association
6820 Deerpath Road
Elkridge, MD 21075
  1. Four outside experts advise Work Group on promising care management strategies

  2. Facilitated discussion between these experts and members of the Work Group

  3. Key goal: To reduce hospital use without creating similar costs elsewhere; building local health system management through having hospital leaders understand the array of services and needs in their most seriously ill population. Effective care coordination can help achieve these goals through a package of services that reflect the patients’ priorities and meet all critical needs. There is a reciprocal obligation to manage the service supply and quality to create good care plans.

  4. What are the main features of the existing landscape? Gaps, many separate initiatives without linkages? How can we develop regional and statewide collaboration to move toward a better model of coordinated care?

  5. Recommendations for action steps

  1. Data Driven Care Coordination Initiatives

  2. MAPMG - Kaiser Permanente

  3. Frederick Memorial Hospital

  4. The Coordinating Center

  5. Bon Secours Baltimore Health System

  6. Live Well San Diego

  7. Webinar Recording

Meetings - 2015

Dates and Location Meeting Goals Meeting Documents
January 7, 2015 

10 – 12 pm

  1. Follow-up discussion on best-practice care management elements and potential for statewide / regional collaboration (i.e., on infrastructure of care management across settings, predictive modeling, IT, work force), including timeline for implementation

  2. Selected stakeholder groups make brief presentations to the Work Group

  3. Decisions on main features of Work Group’s conclusions

January 23, 2015 

9am – 12 pm

  1. Identification of the key elements of a “Toolkit” of Care Management models and practices from which hospitals and others may draw

  2. Development of plan to avert each hospital “reinventing the wheel” by using proven strategies from the Toolkit

  3. Identification of specific communities/regions where a group of hospitals could work together, and with advanced primary care groups and other community organizations to redesign care delivery to reduce the use of avoidable care in high-cost settings

  1. Agenda

  2. Chronic Care Whitepaper

  3. Care improvement and care coordination vision

  4. Medicare Data for Care Coordination

  5. HSCRC Care Coordination Work Group February Meeting Outlines

  6. Proposed Care Coordination Work Group Report Outline

  7. Webinar Recording
February 12, 2015 

2 – 5 pm

  1. Care Coordination Strategies and Priorities Recommendations

  2. Development of action steps, including the roles of state agencies, hospitals, and other key stakeholders

  3. Review first draft of report and suggest improvements

  1. Agenda

  2. Care Planning Handout on Definitions and Background

  3. Care Planning Presentation

  4. Care Plan Example-1

  5. Care Plan Example-2

  6. Care Plan Example-3

  7. Revised Care Coordination Activities Matrix

  8. Draft Recommendation on Data for Care Coordination

  9. Data Sources and Applicability to Care Coordination

  10. HCHD-HCGH HSCRC Presentation

  11. MedChi

  12. The role of Rehabilitation Services

  13. Extended Care Planning

  14. Perioperative Surgical

  15. Webinar Recording
February 27, 2015 

10 – 1 pm

4160 Patterson Ave.
Baltimore, MD 21215
  1. Develop Care Coordination Timeline and Implementation Plan Recommendations

  2. Review second draft report and make recommendations for final changes

  1. Agenda

  2. Opportunities for Maryland Investment in Care Coordination

  3. CRISP Care Management

  4. LifeSpan Recommendations

  5. Complete Packet

    Webinar Recording
March 31, 2015 

1 – 4 pm

Location CHANGED to: 

Maryland Hospital Association
6820 Deerpath Road
Elkridge, MD

  1. Care Coordination Infrastructure Cost: HMA Presentation and discussion

  2. Review and comments on draft Work Group report

  3. Next steps

  1. Agenda

  2. Care Coordination Work Group Draft Report

  3. Opportunities Grid - revised

  4. Care Coordination Infrastructure Cost

  5. CBH Letter

  6. Complete Packet 

    Webinar Recording
Workgroup Meetings Completed.

Regional Partnership Information


Care Coordination Final Report

Public Comments Submitted to the Workgroups

The Workgroup will reserve time at the end of each meeting for brief comments and questions from the public. The public is also encouraged to submit written comments related to Workgroups at any time. Comments may be sent via email to​