Accountable Health Community Profile: Baltimore, MD

Last spring, the Centers for Medicare and Medicaid Services announced a $157 million innovation round focused on building “Accountable Health Communities.” These communitywide partnerships screen patients for unmet social needs and connect them from the health care system to community resources. 

The City of Baltimore won approval for their five-year, $4.2 million Accountable Health Community project designed to "move beyond one-off programs that connect patients to resources and toward a city-wide ecosystem that addresses patients’ social needs comprehensively."

Accountable Health Community Partners

The Baltimore City Health Department convened a diverse coalition of partners, including all seven of Baltimore's major health systems, FQHCs, community-based organizations, social service providers, nonprofit organizations, and neighborhood leaders, including:

  • Major health systems like Bon Secours Baltimore Health System, Johns Hopkins Health System, Medstar Health, Mercy Health Services, and University of Maryland Medical System
  • The regional HIE, Chesapeake Regional Information System for Our Patients
  • FQHCs including Chase Brexton Health Care, Total Healthcare, and Healthcare for the Homeless
  • HealthCare Access Maryland
  • Maryland Medicaid

Accountable Health Community Strategies

This collaborative partnership is built around four key strategies designed to ensure successful implementation of the Accountable Health Communities model:

  • Identify and scale best practices. A unified learning community was created for practitioners and administrators to share experiences in screening populations for unmet social needs, referring and connecting patients to available resources, and closing the loop between referring providers and resources.
  • Gain maximum efficiency. A central hub of trained and supervised community health workers was created to help participating providers manage their panels.
  • Enable unified data-insight and technology systems. An integrated technology system was implemented to provide care team members with insight into a patient’s social needs.
  • Ensure true community partnership. A community advisory board monitors community referral outcomes data with an eye to creating a business case for resource connections and advocating for additional connections and resources as necessary.
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Topics: Accountable Health Communities