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 carecoordination@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.

Case Consultation

Case Consultation provides hospitals with dedicated time to review the status of open cases and collaborate on care coordination for patients with complex needs.

These 15 to 30-minute sessions allow hospitals to:

  • Discuss current cases.
  • Identify potential referrals.
  • Ensure patients are connected to the right community resources for continued support.

To schedule, email carecoordination@211md.org.

211 Hospital & Community Resource Network

The network brings together hospitals, state agencies and community organizations to tackle the challenges faced by patients with complex needs who are discharged from hospital settings and struggle to navigate community resources. These meetings provide a platform to strengthen partnerships, foster collaboration and develop actionable solutions to improve care coordination and patient outcomes.

Purpose of the Meetings:

  • Address gaps in care for individuals transitioning from hospitals to the community.
  • Share innovative ideas and best practices for supporting patients with complex needs.
  • Improve access to and awareness of community resources.
  • Build stronger partnerships between healthcare and community organizations.

If your hospital or organization is not yet part of this critical effort, we invite you to join the conversation. Together, we can create a more seamless and effective care system for Maryland’s most vulnerable populations.

Meetings are held the first Monday of every month.

Additional Resources

Additional 211 Support

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

 

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