Category: Health and Health Care

1 - Connecting the Dots: Partnering with Healthcare Systems to Link Social Determinants of Health, Evidence-Based Healthy Aging Programs, and Wrap-Around Home and Community-Based Services to Improve Population-Based Healthcare

     MAC, Inc. Area Agency on Aging, a community-based organization (CBO), Peninsula Regional Medical Center and Maryland’s Health Information Exchange - Chesapeake Regional Information System (CRISP) are partnering to track individuals across hospitalization, primary care providers and CBO services.  The partners are identifying gaps in care and coordinating patient-centered clinical and social services. Chronic Disease Self-Management and Falls Prevention evidence-based programs (EBPs) are entered in CRISP as community resources for provider referral.  After a patient is referred to an EBP, the CRISP system pushes notification alerts to providers. The CBO receives alerts about clients when hospitalized.

      CRISP data provides hospital/emergency department utilization at 3 months and 6 months pre- and post- EBP. These reports have already generated the following outcomes:  Referrals to EBPs from transitions of care has resulted in reduced  hospital readmissions; Controlled hypertension resulted in a cost savings per patient $460.

     The partnership is also tracking assessment of Social Determinants of Health (SDoH) and referral to ‘wraparound’ nonclinical services, including home-delivered meals, transportation, home modification.  All referrals to EBPs include SDoH assessment for social service needs. 

    Recent statewide survey results of EBP participants indicate that 22% of participants in EBP self-identify as being depressed. Identification of and intervention to reduce depression and social isolation among older adults is critically important in managing healthcare costs. The PEARLS depression screening and intervention and the other EBPs are adding pre-/post- assessment of social isolation.

     MAC oversees a web-based statewide database includes: a calendar and referral/enrollment process for providers and/or individuals to join a workshop; collects workshop pre-/post- clinical measures; documents program fidelity/facilitator certification; is used to maintain quality assurance; links participant data to referring providers; and will be utilized to strengthen CRISP partnerships throughout the state.

       We believe this partnership will provide a roadmap for other CBOs and partnering health systems to document workshop enrollment, social determinants of health (SDoH) needs and home and community-based services in ‘Care Alert’ notification as part of a true population health approach to care.


Sue Lachenmayr

State Program Coordinator
MAC, Inc. Living Well Center of Excellence
Easton, Maryland

Sue Lachenmayr, MPH, CHES, is the State Program Coordinator for MAC, Inc. Living Well Center of Excellence (LWCE). She has over 25 years of knowledge and expertise in training, implementing, evaluating and sustaining evidence-based healthy aging/self-management programs. As State Program Coordinator, she has worked to establish partnerships between healthcare entities and community-based organizations to expand access and sustainability of these programs across the State of Maryland. Previously, she served as Senior Director of the National Council on Aging (NCOA) Center for Healthy Aging Technical Assistance Center. Prior to that, Sue oversaw evidence-based program implementation across New Jersey for the Department of Health and Senior Services.