Baltimore City Health Department Awarded over $4 million to Connect Patients to Critical Community Services


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Mona Rock: Office: (443) 984-2623, Cell: (410) 375-7763
Perry Meyers: Office: (410) 545-0823, Cell: (667) 216-0723

BALTIMORE, MD (April 7, 2017) — The Baltimore City Health Department (BCHD) announced today that the agency has been selected for a $4.2 million, five-year cooperative agreement from the Centers for Medicare and Medicaid Services (CMS) under its Accountable Health Communities (AHC) program to support efforts to implement a comprehensive model that will better connect patients to health-related community and social services.

Under BCHD’s leadership, through the implementation of a community health worker hub and innovative technology tools, this project will empower Baltimore City hospitals and Federally Qualified Health Centers (FQHC) to better identify patients’ social needs, navigate them to essential resources, and collect essential community-level data.

Baltimore City was selected as part of 32 participants for the Assistance and Alignment Tracks of the AHC model.

“We are so proud of what these funds will mean for people across Baltimore,” said Mayor Catherine E. Pugh. "Thanks to this generous funding from our federal partners, the Health Department and all of our hospitals and clinics will be able to bridge the gap between clinical and community service providers across our city and improve outcomes for thousands of Baltimoreans.”

By addressing critical drivers of poor health and high health care costs, the CMS AHC model program aims to reduce avoidable health care utilization, impact the cost of health care, and improve health and quality of care for Medicare and Medicaid beneficiaries. Baltimore City’s AHC model will aim to address the gap between clinical care and community services in the current health care delivery system by working screening, referral, and community navigation services.

“As an emergency physician, I have seen how health outcomes are impacted not only by the medical care we provide, but also by underlying social needs—including housing and food access, transportation, and access to mental health and addiction services,” said Baltimore City Health Commissioner Dr. Leana Wen. “We must systematically identify and address these social needs in order to move the needle on health outcomes. This transformative opportunity will also help us to reduce health care costs, coordinate services, and improve care for our most vulnerable.”

Baltimore City’s AHC model project falls under the AHC Alignment Track, which goes beyond service delivery, to encourage community-level partners are aligned to best ensure that necessary services and supports are available and responsive to the patients’ needs.

In spring 2016, BCHD convened a diverse coalition of partners, including all 7 of the City’s major health systems, FQHCs, community-based organizations, social service providers, nonprofit organizations, and neighborhood leaders. Key implementation partners included:

  • HealthCare Access Maryland
  • Maryland Medicaid
  • Chesapeake Regional Information System for Our Patients (CRISP)
  • Bon Secours Baltimore Health System
  • Johns Hopkins Health System – Johns Hopkins Hospital and Bayview Hospital Lifebridge Health – Sinai
  • Medstar Health -- Good Samaritan, Harbor Hospital, Union Memorial
  • Mercy Health Services
  • University of Maryland Medical System – Midtown and Main
  • St. Agnes Hospital
  • Chase Brexton Health Care
  • Total Healthcare
  • Healthcare for the Homeless

In addition, BCHD will continue to work closely with the Local Health Improvement Coalition and convene an AHC Community Advisory Board to help drive the ongoing vision for the model and ensure that stakeholders and community members across Baltimore have insight into this initiative’s progress.

“We are thrilled to support and collaborate with all of our partners on this innovative approach to address patients’ social needs, as well as to demonstrate the value of such interventions,” said Sonia Sarkar, Chief Policy and Engagement Officer at Baltimore City Health Department. “We are grateful to all of our partners who share our vision of tackling the social determinants of health across communities.”

To view a list of the Assistance and Alignment Tracks bridge organizations in the Accountable Health Communities Model, please visit:

The Accountable Health Communities Model is authorized under Section 1115A of the Social Security Act, which established the Innovation Center to test innovative payment and service delivery models to reduce Medicare, Medicaid, and Children’s Health Insurance Program expenditures while maintaining or enhancing the quality of beneficiaries’ care. For more information about the Accountable Health Communities Model, please visit:

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