Transitions Clinic Opens in Prince George's County

November 27, 2017    |  

A new clinic has begun helping patients who are newly discharged from University of Maryland Prince George’s County Hospital Center to better cope with circumstances that could harm their health and lead to readmissions.

The Interprofessional Care Transitions Clinic (ICTC) is designed to expand access and continuity of care for Medicare, Medicaid, and newly insured patients who lack access to a primary care provider by addressing that gap after their discharge.

Any reduction in readmissions not only would make life easier for patients and their families but would help solve a national problem that amounts to $41 billion a year, according to federal calculations of the medical costs.

Several institutions have joined in this innovative collaboration, with the support of funding from the Maryland Community Health Resources Commission (CHRC), to tackle the issue. Leaders of the University of Maryland, Baltimore (UMB), University of Maryland Medical System (UMMS), and University of Maryland Capital Region Health (UMCRH) held a ribbon cutting ceremony on Nov. 28, 2017.

The clinic is located within the University of Maryland Family Health and Wellness Center on the hospital’s campus in Cheverly, Md.

To facilitate patients’ linkages to providers within the community, the ICTC combines resources of the center and two UMB-managed resources: the Governor’s Wellmobile and an e-Health Center. The clinic is a UMB-managed, interprofessional, team-based clinic that includes pharmacists, nurse practitioners, social workers, and lawyers, many of whom took part in the event.

“The clinic’s model allows the university to bring to bear the power of ‘team,’” says UMB president Jay A. Perman, MD, a pediatrician who conducts his own weekly interprofessional clinic. ”We need more data on this type of care but what data we have is promising.” For example, evidence shows that patients with chronic illnesses receiving team-based care make fewer emergency department visits than those receiving traditional care and are hospitalized less frequently.

“If we can connect vulnerable patients to a primary care provider and a team of health and social services professionals,” Perman says, “these patients are less likely to find themselves back in the hospital.”

Services provided by the ICTC are funded by the University of Maryland schools of pharmacy, nursing, social work, and law in collaboration with UM Prince George’s Hospital Center and the CHRC, which awarded a two-year, $1.2 million grant to UMB in March 2017.

“This important and innovative project will help expand access to health care for vulnerable populations in Prince George’s County,” says Mark Luckner, the CHRC executive director who is expected to participate in the ceremony. “The Commission is thrilled to support this project, which is innovative, sustainable, and replicable.”

The ICTC has “transitions” in its name because it offers patient-centered services to hard-to-reach and high-utilizing patients who are undergoing transitions in care.

Transitions, such as moving from hospital to home or hospital to long-term care facility, increase the risk of adverse events due to the potential for miscommunication as responsibility is given to new parties, according to the Agency for Healthcare Research and Quality, which also notes that hospital discharge is a complex process representing a time of significant vulnerability. Nationally and locally, measures are in place to reduce readmissions.

The new clinic’s model is to provide continuity of care as people go through these transitions, which may also include release from an emergency department after an urgent health issue. To do so, the ICTC relies on three elements: services provided at the UM Family Health and Wellness Center; services offered by the Wellmobile at locations in Bladensburg, Greenbelt, Langley Park, and Laurel; and an e-Health Center that connects with patients via telephone.

The ICTC, which has been seeing patients for several months in anticipation of its formal opening on Nov. 28, expects to care for 1,200 to 1,500 people in Prince George’s County over the two- year period. The intent is to link them to primary care providers within 60 days, despite gaps in the county’s provider workforce.

The clinic’s objectives are to address patients’ needs across the continuum of interprofessional practice by utilizing nurse practitioners, clinical pharmacists, nurse care managers, and lawyers and social workers to reduce wait time for follow-up appointments post-discharge from the hospital or emergency department; and to increase the percentage of patients receiving transitional care in the community post-discharge, among other things.

“This expanded, interprofessional team care model will meet patient needs where they are –either at the clinic or right in their neighborhoods –creating flexibility and innovation in a true, patient-centric model, says Magaly Rodriguez de Bittner, PharmD, FAPhA, a professor and associate dean at the UM School of Pharmacy who oversees the interprofessional clinic.

About UMB

Founded in 1807, the University of Maryland, Baltimore is Maryland’s only public health, law, and human services university, dedicated to excellence in education, research, clinical care, and public service. UMB enrolls 6,500 students in six nationally ranked professional schools — medicine, law, dentistry, pharmacy, nursing, and social work — and an interdisciplinary Graduate School. The university provides more than $40 million each year in uncompensated care to Maryland citizens, and receives more than $500 million in extramural research funding annually. For more information about the University of Maryland, Baltimore, visit

About UM Capital Region Health

University of Maryland Capital Region Health (formerly Dimensions Healthcare System) was formed in 1982 as an integrated, not-for-profit healthcare system serving the citizens of Prince George’s County and the surrounding area. Our mission is to provide high-quality, accessible healthcare services in partnership with our community. UM Capital Region Health and University of Maryland Medical System will usher in a new era of healthcare for Prince George’s County with the opening of a new Regional Medical Center in 2021.

About Maryland CHRC

The CHRC was created in legislation approved by the Maryland General Assemblty in 2005 to expand health care access in Maryland’s underserved communities and help reduce avoidable hospital emergency department visits and hospitalizations. These projects have collectively served more than 330,000 Marylanders with complex health and social service needs.