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Howard Health Partnership’s 3-Part Community Approach to Population Health

Howard Health Partnership’s 3-Part Community Approach to Population Health

The partnership, which includes Howard County General Hospital, addresses the needs of high health care utilizers.

With nearly $1.5 million in grant funding from the Maryland Health Services Cost Review Commission, Howard County General Hospital is well on its way to establishing a community population health model to reduce health care costs and improve outcomes.

The program, called the Howard Health Partnership, targets Howard County adults who have Medicare, are eligible for both Medicare and Medicaid, or have had at least two encounters with the hospital in the past year, including inpatient stays and Emergency Department visits. Some 80 percent of the targeted population is 65 or older, and 66 percent have multiple chronic conditions. The partnership, which started last fall, comprises Howard County General Hospital and other community groups, and has the support and participation of organizations including the local health department, Horizon Foundation and members of the local health improvement coalition.

“Through a collaborative community process, we put together an intervention framework that helps address the needs of high health care utilizers,” says Elizabeth Edsall Kromm, the hospital’s vice president of population health and advancement. “We focus on the social determinants of health in addition to making sure we offer the right clinical care. Our Community Care Team of community health nurses, licensed clinical social workers and other community health workers not only addresses patients’ clinical needs, but also conducts home visits to try to address any social needs, whether it’s food insecurity, transportation or physical issues requiring modifications to patients’ homes so they can remain in place longer and live independently.”

The partnership’s numerous interventions fall in three categories: complex care management, care transitions and self-management supports. As part of complex care management, the hospital established its Community Care Team for primary care coordination and is working with Johns Hopkins Home Care Group on remote patient monitoring. This home-based program for patients with heart failure, diabetes or chronic obstructive pulmonary disease provides daily monitoring by a nurse case manager as well as disease education. Through Gilchrist Services’ Support Our Elders Program, nurse practitioners and case managers provide in-home medical care for homebound, frail elderly with chronic conditions.

To deliver seamless care transitions, the hospital has partnered with Way Station Inc., a subsidiary of Sheppard Pratt Health System operating an outpatient mental health clinic in Columbia, to offer rapid access for urgent behavioral health needs. Patients presenting to the hospital’s Emergency Department with such needs are connected to Way Station within two business days and are provided initially with up to six counseling visits and two prescriber visits. The hospital also is part of a skilled nursing facility collaborative that provides standard care pathways for conditions like heart failure and sepsis, and can refer patients to the Community Care Team after discharge.

Additionally, the Howard Health Partnership offers self-management supports, such as classes from the Office on Aging on how caregivers can care for themselves and their loved ones and navigate the health system. Journey to Better Health is a faith-based program offering screening, classes and social support for those with conditions like hypertension and diabetes. Many of the partnership programs are free or subsidized for eligible participants.

“The whole point is to identify the risk factors of patients in the community and keep them healthy and out of the acute care setting,” says Steven Snelgrove, Howard County General Hospital president. “We’re very pleased by how things are going.”

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