Community Based Care Coordination
MAC, as an Area Agency on Aging, is addressing the social determinants of health through its MAC Plus program.
This free program connects people to services to enable them to continue to live safely and independently in their home following a hospitalization.
Services may include:
- Nutritional screening
- Financial review to determine eligibility for assistance
- Social support
- Regular Phone check-ins by a Community Health Worker and a Registered Nurse
Person-Centered Hospital Discharge Planning
A nurse from the MAC Plus program will assist the client in identifying potential obstacles in maintaining their independence. Once those concerns are identified appropriate resources and services will be recommended.
The MAC Plus program is a year- long program that partners a nurse and a community health worker to each client. Through this relationship ongoing assessments are performed to identify new areas of concern and to address those concerns as they arise.
Age 60 or older or disabled adult
Risk of long-term institutionalization
Wicomico County resident
Referrals can be faxed attention to Sara Shearer RN at 410-742-0525
For more information:
Sara M. Shearer RN
410-742-0505 Ext. 169