Accountable Health Communities (AHC) is a city-wide project led by HealthCare Access Maryland (HCAM), in partnership with Baltimore City Health Department and 10 clinical delivery sites. AHC works to reduce utilization of Emergency Departments by diverting high utilizers to community resources and linking them to appropriate services that address their social determinants of health.
In Baltimore City, many hospitals and clinics are using the Accountable Health Communities screening to understand and document the social needs of city residents and connect clients to resources such as food, jobs, mental health, education, finances, housing utilities and transportation.
Clinical Delivery Sites Participating:
- Chase Brexton Health Services
- Saint Agnes Hospital
- University of Maryland Medical Center
- University of Maryland Medical Center Midtown Campus
- MedStar Harbor Hospital
- MedStar Union Memorial Hospital
- MedStar Good Samaritan Hospital
- Mercy Medical Center, Labor & Delivery Unit and Center for Advanced Fetal Care
- Johns Hopkins Bayview Medical Center
- The Johns Hopkins Hospital
The HCAM team of Community Health Workers (CHW) provide telephonic navigation services and outreach to eligible clients. On a rare occasion, a home-visit is scheduled to connect clients to needs identified from the screening. Partnership is key with this initiative.
Key components of the program include the following:
Stakeholder partnerships— Baltimore City Health Department, CMS, 10 clinical delivery sites, CRISP and State Medicaid are all active partners with HCAM, the navigation HUB, for the project.
Documentation—HCAM team will record all activities and information in HCAM’s internal case management system. Case summary notes are shared with referring clinical delivery sites and insurance companies for continued care coordination.
Prevention of Duplication of Service— HCAM team will research each individual referred client to see if they are currently enrolled in care coordination. If it is determined that they are actively enrolled, the HCAM team will reconnect the client back to the program for ongoing care, preventing duplication of services.