About Us
overview
The Baltimore City Health Department (BCHD) and Health Care Access Maryland (BCHD/HCAM) were awarded a grant from the Center for Medicaid and Medicare Innovation (CMMI) to design, implement, and evaluate a city-wide Accountable Health Communities (AHC) model that will address beneficiaries' health-related social needs and drive stakeholder alignment with social needs resources.
background
Addressing health-related social needs is essential to improving population health and wellness. Although Baltimore City is home to some of the best healthcare institutions in the country, it also experiences enormous health disparities.
Medical literature shows that more than 70 percent of health outcomes are driven by social factors, not clinical care. Unmet health-related social needs, such as food insecurity and inadequate or unstable housing, may increase the risk of developing chronic conditions, reduce an individual's ability to manage these conditions, increase health care costs, and lead to avoidable health care utilization.
BAHC is committed to identifying and addressing the health-related social needs of Baltimore City's residents by linking clinical-community with community resources that will reduce total health care and utilization costs.
Core components
Social needs screening
Medicaid and Medicare beneficiaries at participating healthcare providers will be screened for any social health related needs.
Navigation Referral
Qualifying beneficiaries will be referred to an AHC navigation hub housed at HCAM to receive support with accessing services.
Resource Directory
Navigators and community organizations will access an comprehensive directory to help them find the best resources for patients.
Care & Community Alignmentt
Healthcare, community, and city/state agency partners are convening to enable and evaluate the clinic-community linkages in Baltimore.
Project goals
Identify social needs
Effectively identify patients' health related social needs. Screen ~40,000 Medicaid and Medicare beneficiaries annually.
Successful Referrals
Connect patients with case management to ensure they access the resources they need. Refer ~3,000 qualifying beneficiaries annually to AHC hub for navigation. Provide community referral summaries to beneficiaries who do not receive navigation.
Create Unified Systems
Create unified systems and technology to support stakeholders with screening and resource navigation.
Push Integration
Make the case that integration of social needs into clinical care is effective and cost-effective.
Get involved
Is your organization building a resource directory, providing resources to Baltimore residents, or interested in partnering? Let us know! Reach out to us with any questions and we'll get back to you ASAP.
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Partners
The Baltimore City Health Department is the oldest, continuously-operating health department in the United States, formed in 1793, when the governor appointed the city's first health officers in response to a yellow fever outbreak in the Fells Point neighborhood. During the more than 220 years since then, we've been working to improve the health and well-being of Baltimore residents. We strive to make Baltimore a city where all residents realize their full health potential.
The Health Department has a wide-ranging area of responsibility, including acute communicable diseases, animal control, chronic disease prevention, emergency preparedness, HIV/STD, maternal-child health, restaurant inspections, school health, senior services and youth violence issues. The agency includes a workforce of approximately 800 employees and has a budget of approximately $126 million.
Overseen by a committed and diverse Board of Directors, HealthCare Access Maryland is a nonprofit agency that connects residents to public health care coverage and helps them navigate services effectively. We work with individuals, hospitals, policymakers, and social services organizations to strengthen Maryland's health care delivery system and make Maryland healthier.
Each year, our 200+ employees connect more than 145,000 uninsured and underinsured clients to health insurance, health care, and vital community resources to impact ones social determinants of health. Our programs and services are designed to bridge gaps in services to pregnant and postpartum women, immigrants, people experiencing homelessness, youth in foster care, people with substance use disorders, individuals recently released from jail, and others.
Fearless is a privately-owned, Baltimore-based digital services firm. We specialize in Design, Development, Data Analytics, Geospatial and Agile Coaching. Fearless maintains a team that can work across the entire technology stack, from complex visualizations that offer intuitive user experience and interfaces, to applications that span millions of users. We leverage an iterative, agile approach that allows us to incrementally deliver working capability in days to weeks, not months to years. We treat all aspects of the tech stack as building blocks from which to create optimal solutions that improve our customers' workflows, efficiencies, and bottom lines. We exist to deliver Software with a Soul, and ensure that good tech powers the things that really matter.