VIable

NDHI
NAT IONAL DIALOGUE FOR
Healthcare Innovation
Maxim Transition Assist
to Reduce Preventable
Readmissions
Organization Overview
• Maxim Healthcare Services is a nationwide provider
of home health, medical staffing, and wellness
services
• Maxim’s mission is to provide reliable, safe, and
patient-centered care through innovation and efficient
care delivery models
Background
The transition from hospital to home is a high-risk period
for preventable hospital readmissions. Readmissions often
relate to underlying psychosocial and environmental
factors that reduce patient engagement, medication
adherence, and care access. Many of these factors
are beyond the capacity of traditional caregivers
to address.
Maxim recognized the need for innovative ideas to
overcome these psychosocial and environmental barriers.
Maxim Transition Assist (MTA) was developed to
reduce 30-day preventable readmissions by providing
transitional care to patients at high risk for readmission
and empowering them to engage in their own care.
Program Details
In 2015, Maxim initiated a partnership with the University
of Maryland St. Joseph Medical Center (UMSJMC)
to reduce preventable 30-day hospital readmissions
among high-risk patient populations in Maryland. The
program will continue through June 2019.
Objectives of the program are to:
Patients in the program receive the following services:
• Technology Assessment: Incoming patients
undergo an automated assessment of post-discharge
readmission risk based on comorbidities, caregiver
availability, mobility, and other factors
• NP Assessment: For high-risk patients, a nurse
practitioner (NP) conducts a more detailed in-person
assessment at the patient’s bedside and develops
a care plan
• Address the medical and psychosocial factors of
patient populations at high risk for readmission
through community-based care coordination
• Reduce the incidence of 30-day readmissions and
other adverse care outcomes, such as avoidable
Emergency Department utilization
An Initiative of the
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Maxim Transition Assist to Reduce Preventable Readmissions