The Howard Health Partnership (HHP), a regional population health model, delivers effective, community-based and financially sustainable care that improves the patient experience.
Chronic Disease Assistance: Community Care Team (CCT)
The CCT provides community-based, comprehensive support and coordination using a patient-centered approach. Patients and their caregivers generally receive benefits from the program for 30-90 days with frequent home visits and/or phone contact from a multi-disciplinary care team. The first conversation with a CCT member occurs while a patient is in the hospital or within a few days of leaving the hospital. CCT connects patients to primary, behavioral and specialty care; coordinates home care; and addresses social needs by linking patients and their caregivers to appropriate community resources. For information, call 410-720-8788 or email firstname.lastname@example.org.
Within the Hospital
Patients who arrive in the emergency department can benefit from the assistance of a community health worker to coordinate community program and service referrals. Patients with urgent mental health needs that can be addressed with an outpatient appointment receive support through the Rapid Access Program, which makes same or next day appointments at a community outpatient mental health clinic.
Our collaboration with local skilled nursing facilities, such as Lorien Health System and Ellicott City Health and Rehabilitation standardizes the discharge process from the hospital to skilled nursing facilities. These organizations use evidence-based practices to develop and implement disease-specific care pathways for heart failure and sepsis, which are supported by regular rounding of specialists at Lorien’s Columbia location.
Specialized Care Coordination: Journey to Better Health
Journey to Better Health works with faith communities to support the health of their members and other Howard County residents. The program includes chronic disease screenings, self-management education, and support networks developed at each congregation. For information, call 410-720-8788 or email email@example.com.
Gilchrist Services offers a variety of services to patients with advanced illnesses including an in-home medical care program for home-bound frail elderly; a care choices program for hospice-eligible patients with cancer, COPD, congestive heart failure, and HIV/AIDS; and a care coordination program for those discharged from hospice. For more details or to make a referral, call 443-849-6257.
In addition, community health workers are embedded in high-volume primary care practices to connect patients to the CCT and other community resources.
Support Tools for Care Coordination
Remote Patient Monitoring is a home-based program for patients with congestive heart failure, diabetes and COPD to receive daily monitoring by a registered nurse.
The Howard County Health Department is developing a web-based tool to assess a high-risk patient’s social support needs, recommend community resources, track referrals and provide information to the CCT.
The Howard County’s Office on Aging and Independence funds and delivers a program designed for caregivers, Powerful Tools for Caregivers, which has been shown to have a positive impact on caregiver health.
While HHP works with Howard County’s Local Health Improvement Coalition (LHIC) to address priority areas to improve the health of the broader community, it is initially focusing on serving people who meet the following criteria:
- Howard County resident
- 18 years of age or older
- Medicare beneficiary
- History of two or more hospital encounters in the last 12 months*
*One encounter is defined as an inpatient admission, an observation stay or an Emergency Department visit.
Providers and Agencies
The Howard County Health Department and the Horizon Foundation generously provides funding to support several of these efforts. Other collaborators, including Howard County's Local Health Improvement Coalition, Howard County's Office on Aging and Independence, Lorien Health Systems, Johns Hopkins Home Care Group, Gilchrist Services and Way Station, Inc., help connect people to services and help better manage their health.