West Baltimore Collaborative

The West Baltimore Collaborative (established in May, 2017) is a regional partnership between HCAM and four area hospitals (University of Maryland Medical Center, University of Maryland Midtown, St. Agnes and Bon Secours), formed to manage the needs of high-utilizer patients and redirect them to primary care and services that address both their medical and social needs. In-bedded HCAM care coordinators work closely with the hospital inpatient transitional care teams to identify eligible clients, and connect them to post-discharge care management services. This program targets individuals with multiple high-risk chronic conditions, with the goal of connecting them to specialty medical care and reducing their emergency department use and keeping them out of the hospital.

This program focuses on Medicare and Dual eligible patients who reside in specific West Baltimore zip codes (21201, 21216, 21217, 21223 and 21229) and who have specific chronic conditions (Hypertension, Chronic Obstructive Pulmonary Disease, Diabetes and/or Congestive Heart Failure) and/or a managed mental health (depression, anxiety, etc.) and/or substance use condition. This program also uses technology, through the Chesapeake Regional Information System for our Patients (CRISP), to better understand the utilization patterns of specific patients, which allows the care coordination team to better understand a patient and coordinate care more efficiently. This program has also allowed for more integration of medical documentation systems and sharing of resources, care plans, and care alerts between program partners.


Core Program Goals 

  • Short-term case management for patients that have encounters in both inpatient and emergency department settings;
  • Connecting high utilizers to appropriate levels of care, in order to reduce thirty-day hospital re-admissions, emergency room visits, and other unscheduled acute care visits; and
  • Closely monitoring elements of the care management process (e.g. telephone outreach, primary care follow-up, medication reconciliation, home visits) to determine which combination of interventions provides the optimal care outcomes for these patients.


Core Program Activities:

  • Comprehensive patient assessment that complements the participating hospitals’ discharge plan and includes social, medical, economic and environmental factors;
  • Care coordination that supports the patient’s health goals and facilitates holistic wellness;
  • Participation in multi-disciplinary team meetings with the provider community to facilitate a coordinated care experience;
  • Development of care plans, and continuous care plan re-evaluation with input from the patient, HCAM staff and hospital partners
  • Linkages, referrals and access to applicable social services and/or community-based and client-specific resources;
  • Review of Chesapeake Regional Information Systems for Our Patients (CRISP) Encounter Notification Service-Proactive Management of Patient Transitions (ENS-PROMPT) alerts to determine utilization outside of the participating hospitals; and
  • Health system navigation, education, and support


The West Baltimore Collaborative program employs six HCAM staff: Four Care Coordinators (one in-bedded at each hospital site), and two RN Medical Case Managers (to support the care coordination team, train staff on best practices and community resources, and to review high risk cases). These staff work closely with the rest of the HCAM agency programs to connect their clients to the appropriate community based program and services, in accordance with their needs.


Please contact Lynell Medley, VP Programs (lmedley@hcamaryland.org) for any information related to the West Baltimore Collaborative, or other Population Health programs at HCAM.