211 Hospital Transition Program

We Help Maryland Hospitals

In partnership with the Maryland Department of Aging, the 211 Hospital Transition Program facilitates referrals and assistance services to support older adults and adults with disabilities. The program assesses and addresses their long-term care needs.

You can also call 211 and Press 4.

For additional questions, email agingcc@211md.org

How the Program Works

Refer older adults and adults with disabilities during regular business hours (Daily, 9 a.m. - 5 p.m.).
Referrals received during nonbusiness hours will be acknowledged by 9 a.m. the next business day.

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Acknowledge

211 Care Coordinators will acknowledge your referral within 30 minutes of receipt. The Care Coordinator will follow-up with the patient and begin identifying available resources using 211's comprehensive database.

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Connect

211 Care Coordinators will assess patients to understand their needs and resources and develop a plan of action.

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Follow-Up

211 Care Coordinators will engage patients in providing preventative services for a follow-up period of 120 days.

hopsital worker coordinating care

Which Patients Should Be Referred?

Refer these patients:

1. Older adults and adults with disabilities who are at risk of institutionalization, nursing facility placement, Medicaid eligible, or in need of other community-based resources to reduce unnecessary repeat hospitalizations.

2. Assistance is needed in locating older adult or adult with disability resources.

3. The patient provided consent.

211 Case Consultation Services

Have a complex case? Let our 211 Care Coordinators help you solve complex patient cases.

"Case consultation services have proven to be a useful tool for engagement and collaboration."

Maria Manna

Northwest Hospital, Director of Care Management

 

211 Hospital Network 

Connect with 26 other hospitals, state coordinators, the Behavioral Health Administration (BHA) staff and other state partners during the 211 Hospital Network monthly meetings.

Participants discuss best practices, identify gaps in service, and develop long-term, sustainable solutions. This collaborative initiative aims to navigate the dynamic healthcare delivery system and support a holistic approach to patient care. Together, we can identify and implement collective strategies to enhance population health.

 

 

Additional Resources

Additional 211 Support

211 Care Coordination
(Emergency room patients needing behavioral health support)

 

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