Frederick Health operated a home health program for patients with complex care needs, but noticed a high readmissions rate and avoidable ED use.¹ Due to Maryland’s reimbursement model, where hospitals charge the same amount for their services regardless of insurance coverage, and providers are paid more when patient outcomes are better, leaders at Frederick Health wanted to create a care management solution to help provide additional monitoring for chronic care patients and reduce unnecessary readmissions for patients transitioning out of the home care program.²