Baltimore Accountable Health Community

Recent Updates

The Baltimore City Health Department has been awarded a $4.3M grant from the Center for Medicaid and Medicare Innovation (CMMI) over 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.

Addressing health-related social needs is essential to driving population health and wellness in Baltimore. Medical literature shows that more than 70% 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 AHC 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.

Baltimore AHC Model Core Components:

  • 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 to support the 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

Baltimore AHC Model Goals:

  • Effectively identify patients’ health-related social needs and connect them, based on those needs, to critical resources successfully;
  • Create unified systems and technology to support all the stakeholders involved with screening and resource navigation;
  • Conduct back-end data collection to drive ongoing quality improvement; and
  • Make the case that the integration of social needs into clinical care is effective and cost-effective.

Specifically, the AHC should be:

  • Approaching screening ~40,000 Medicaid and Medicare beneficiaries annually
  • Referring 2,925 qualifying beneficiaries (2+ ED visits) annually to the AHC hub for navigation
  • Successfully providing community referral summaries through our technology platform to those who do not receive navigation
  • Tracking patient referrals to determine success in securing resources/services through HCAM navigation
  • Develop workflow, technology system, data-sharing, quality improvement, and community engagement infrastructure to support the above


As the bridge organization, the Baltimore City Health Department will work with HealthCare Access Maryland (HCAM), the AHC hub partner where the AHC community resource navigators will be based.

Bridge Organization: BCHD
Implementation Partner: HealthCare Access Maryland (HCAM)
CMS Partner: Maryland Medicaid

Hospital/FQHC Partners:

  • Bon Secours
  • Chase Brexton
  • Healthcare for the Homeless
  • Johns Hopkins (JHH/Bayview)
  • University of Maryland (Midtown/Main)
  • Medstar (Union Memorial, Harbor, Good Sam)
  • Mercy Medical Center
  • Sinai
  • St. Agnes
  • Total Healthcare

Social Services Partners (Reps):

  • Baltimore City Community College
  • Behavioral Health Systems Baltimore
  • Druid Heights Community Development Corporation
  • House of Ruth
  • Humanim
  • Department of Human Resources
  • Moveable Feast
  • Project Plase

Hospital Partner Roles

Our hospital partners will specifically contribute to this project by:

  • Participating in model design & community advisory board
  • Screening beneficiaries (ED, L&D, Psych)
  • Referring beneficiaries to AHC navigators
  • Input to technology & quality improvement

Additional resources: Baltimore Accountable Health Community Overview Document

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