Accountable Health Community (CMS Grant)

The Accountable Health Community Grant:

Addressing health-related social needs is essential to driving population health and wellness in Baltimore. 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. As Medicare and Medicaid beneficiaries make up nearly 60% of the total population in Baltimore, the Baltimore City Health Department (BCHD), in partnership with HealthCare Access Maryland (HCAM), Maryland Medicaid, Baltimore City health systems, federally qualified health centers (FQHCs), and community-based organizations (CBOs), is committed to identifying and addressing the health-related social needs of Baltimore City’s Medicare and Medicaid beneficiaries via clinical-community linkages that will impact total health care costs, reduce utilization, and improve health outcomes for this vulnerable population.

BCHD/ HCAM and partners have been awarded a $4.3M grant from the Center for Medicaid and Medicare Innovation (CMMI) over the next five years to design, implement, and evaluate a city-wide Accountable Health Communities (AHC) model that will both address beneficiaries’ health-related social needs as well as drive stakeholder alignment with social needs resources.

The core components of the Baltimore City AHC model will include:

  • Health-related social needs screening for Medicaid and Medicare beneficiaries at all participating healthcare providers
  • Referral of qualifying beneficiaries to an AHC navigation hub housed at HCAM, to receive navigation support in accessing social needs-related services
  • Comprehensive technology, data, and quality improvement infrastructure to support resolution of health-related social needs, track outcomes, and drive ongoing program improvement
  • Convening of healthcare and community stakeholders and city/state agency partners to drive alignment around both enabling and evaluating clinic-community linkages within Baltimore City.

For more information, please contact Lynell Medley, RN, VP Programs