Mary's Center

Program Name: Mary's Center's Patient Centered Medical Home Chronic Care Initiative (PCMH-CCI)

Grant Amount: $596,665/3 years

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Mary's Center for Maternal and Child Care, Inc. delivers health care, education and social services to save lives, stabilize families, and strengthen communities. Mary's Center operates three centers and will soon open the fourth center in Prince George's County.

The proposed Chronic Care Initiative will operate at all Mary’s Center locations. This program will apply an integrated approach to the needs of the asthmatic, hypertensive and diabetic populations by utilizing the integrated model in place at Mary's Center, and strengthening the team, through care planning and the utilization of the universal care planning tool with their EMR. This builds on an integrated approach to diabetes which has been piloted over the last 12 months via a “rotational clinic,” so-called because patients meet with all members of the care team – clinician, nursing, health education, nutritionist and family support worker one after another during the course of one extended visit. Specifically, the program will add a RN chronic care case manager who will complete care plans with patients that will encompass the goals of all the team members, adding two panel managers who will ensure that patients are receiving all the services necessary to ensure optimum management of their condition, and adding a health educator with a focus on hypertension to complement the current staffers who focus on asthma and diabetes. The grant will support a panel manager (medical assistant), chronic care case manager, chronic care educator, equipment and supplies.

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