This year, Atlantic General was recognized for pioneering programs that
have improved patient outcomes, thereby drastically reducing preventable
Atlantic General Hospital is currently ranked No. 4 in the state of Maryland
for readmission prevention, with a rate of 9.93 percent (the state average
is 12.85 percent). A readmission is usually defined as a patient’s
being hospitalized again within 30 days of an initial hospital stay.
“The profound success of our accomplishments can only be attributed
to the commitment and collaboration of our associates and medical staff
within the hospital and community settings,” said Charles Gizara,
RN, director of clinical integration at Atlantic General Hospital.
Efforts began in 2014 with the establishment of the Potentially Avoidable
Utilization (PAU) team, which focuses on integrated care coordination
to prevent avoidable hospital readmissions while improving patient outcomes
across the continuum of care.
The PAU team meets each month to review Atlantic General’s performance
compared to state of Maryland outcomes data and evaluate opportunities
to improve community health through collaboration with health care professionals
outside the traditional hospital setting.
Members include internal AGH clinical staff and physicians as well as
community members from the Worcester County Health Department and local
home health agencies and skilled nursing facilities.
Examples of innovative programs that have contributed to successful readmission
reduction at Atlantic General Hospital:
Condition R – The early identification of a potential readmission. This program provides immediate intervention by a registered nurse case
manager for any patient in the Emergency Room who has had a previous admission
within the last 30 days.
The case manager meets with the patient and family to develop a personalized
plan of care to treat underlying chronic conditions that may have led
to the ER visit and get them on the path to better health.
Telehealth Collaboration with Berlin Nursing and Rehabilitation Center. A telemedicine program allows physician consultations to be performed
for patients who have transferred from Atlantic General Hospital to Berlin
Nursing and Rehabilitation Center if there is a change in their medical
An AGH provider will perform an exam by video with assistance from the
facility’s clinical staff in the privacy of the patient’s
room and recommend interventions to prevent readmission when possible.
Since the program’s implementation, readmissions of patients previously
discharged to the rehabilitation center have been reduced by 70 percent.
AGHRx RediScripts Pharmacy Concierge Program. The RediScripts Concierge Program helps close the medication safety loop
by working closely with a patient’s care team to review and fill
all of a patient’s discharge prescriptions. A concierge technician
will deliver the medication directly to the bedside and call upon a pharmacist
to provide personalized education on the medications. For the most critical
patients, a pharmacist will place a follow up phone call to the patient
within 72 hours of discharge to ensure that patients are taking their
medication as prescribed and have all of their questions answered. More
than 80 percent of inpatients opt in to take advantage of the AGHRx RediScripts
Transitions in Care Program. – A dedicated registered nurse care coordinator works with patients
during their transition from inpatient to community setting (home, rehabilitation
center, etc.). The care coordinator works with the patient, primary care
provider and community liaisons for a period of 31 days and serves as
the patient advocate.
If services are required beyond this time, the patient may be referred
to Atlantic General’s Patient Centered Medical Home. Less than eight
percent of Transition in Care patients are readmitted to the hospital setting.
Caption: Atlantic General Hospital receives the Circle of Honor Patient
Safety Innovation Award during the 2016 Maryland Patient Safety Conference.
From left: Bob Yocubik, RN, director of quality at Atlantic General Hospital;
Charles Gizara, RN, director of clinical integration at Atlantic General
Hospital; Joan Lunden, 2016 Maryland Patient Safety Conference keynote
speaker; Jeff Kukel, Pharm D., manager of AGHRx RediScripts Pharmacy;
Robert H. Imhoff, III, president and CEO of the Maryland Patient Safety
Center; and Michael Franklin, president and CEO of Atlantic General Hospital
and Health System.
About Atlantic General Hospital
Atlantic General Hospital has been providing quality health care to the
residents of Worcester, Wicomico, Somerset (Md.) and Sussex (Del.) counties
since May 1993. Built by the commitment and generosity of a dedicated
community, the hospital’s state-of-the-art facility in Berlin, Md.,
combines old-fashioned personal attention with the latest in technology
and services. It provides quality specialty care such as weight loss surgery,
orthopedics, outpatient infusion for individuals with cancer or blood/autoimmune
disorders, retina surgery and a comprehensive women’s diagnostic
center. Atlantic General Health System, its network of more than 40 primary
care providers and specialists, care for residents and visitors throughout
the region. For more information about Atlantic General Hospital, visit