U. of Maryland BWMC Recognized for Population Health Initiatives
Two population health initiatives at the University of Maryland Baltimore Washington Medical Center (UM BWMC) were recognized recently by the Maryland Patient Safety Center with Circle of Honor awards at the 2025 Minogue Award Ceremony.
The first award recognized the collaborative project between Adfinitas Health, Complete Care Severna Park, and UM BWMC, which developed an evidence-based protocol aimed at reducing hospital readmissions for sepsis-recovering patients discharged to skilled nursing facilities (SNFs).
Sepsis is one of the top 10 most preventable complications and a leading cause of readmissions in Maryland, according to the Maryland Patient Safety Center and Maryland Hospital Association.
Traditionally, SNFs have lacked standardized, proactive protocols to support sepsis recovery, leading to reactive care and avoidable hospitalizations. This collaboration filled that gap with a structured, evidence-based clinical pathway designed specifically for the SNF environment.
“This is truly a partnership for post-acute patients,” said Jennifer Bistrack, M.P.H., M.S., R.N., population health nurse and post-acute care program manager at UM BWMC, in a statement. “In today’s regulatory environment, having collaboration at this level is monumental.”
The pilot program, launched by Adfinitas partners at Complete Care Severna Park, monitored 34 newly admitted sepsis-recovering patients over 10 months. Only seven patients (20.6%) were readmitted, compared to a baseline rate of 29.2%, with early signs of decline detected in another seven patients, allowing interventions that prevented hospital transfers.
This initiative not only improves patient outcomes but also reduces healthcare utilization and costs,” Bistrack added. “It’s a model for how hospitals and post-acute partners can work together to deliver safer, more effective care.”
During the awards ceremony, Stephanie Peditto, M.H.S., president and CEO of the Maryland Patient Safety Center, emphasized the groundbreaking nature of the recognition, stating that the UM BWMC-Afinitas-Complete Care award represents the first time a patient safety award has gone to a cross-organizational partnership.
Due to its success, the Sepsis-Recovery Pathway is being adopted as a standard protocol by a growing number of SNFs covered by Adfinitas in Maryland and Delaware.
BW CARES
The second UM BWMC population health honored initiative, BW CARES: From the Hospital to Home and Beyond, is a comprehensive program that addresses social barriers of health during and after a patient’s hospital stay. “There has always been a question by community members of where can I go for help,” said Cheryl Ruff, senior director of practice operations for primary care, pediatrics and population health at UM BWMC, in a statement. “Our program is designed to help break down barriers and increase access to care and services to better address the needs of the community.”
A critical innovation within the program is the travel team, a multidisciplinary group that includes a registered nurse, social worker, community health workers, pharmacist and referral coordinator. Together, they conduct in-person home visits for high-risk patients to address real-life challenges such as transportation access, food security, medication management, and housing safety.
By addressing both clinical and non-clinical needs, they work together to prevent avoidable hospital readmissions and support long-term recovery.
Early outcomes of the program have shown promising reductions in emergency department visits, hospital charges, and readmission rates — emphasizing the value of integrating social support into clinical care.
