More Than Just a Partnership: Why a Hospital and a Community-Based Organization Joined Together to Provide Population Health


Peninsula Regional Medical Center and MAC, Inc – Maintaining Active Citizens – Area Agency on Aging (AAA) and its Living Well Center of Excellence are leveraging home and community-based programs and services to provide support for patients who are ready to return home by extending the continuum of care to reduce readmissions/re-hospitalizations.

This December 13th, 2017 webinar describes the value that this partnership brings to the AAA, the healthcare system, providers, and most importantly, to the people being served. Presenters describe how the relationship began, the value a community-based organization (CBO) adds to service delivery and improved health outcomes; the types of patients who can be helped; the culture change needed to make the partnerships work; and the roles of the healthcare system and the CBO.

Presenters describe how this population health model benefits the health care system and share progress and outcomes to date, including impacts on patients and providers. The current initiative accessing the statewide hospital reporting system Chesapeake Regional Information System for Patients (CRISP) to determine the ROI of evidence-based programs in reducing health care admissions, readmissions and length of stay are described.



Leigh Ann Eagle, BS, Director of the Health & Wellness Program at MAC, Inc. and the Executive Director of the Living Well Center of Excellence (LWCE)

Sue Lachenmayr, MPH, CHES, State Program Coordinator for the MAC, Inc. Living Well Center of Excellence (LWCE)

Katherine Fiddler, DNP, MS, RN, NE-BC, Executive Director for Population Health Services at Peninsula Regional Medical Center (PRMC)