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Healthy Howard's Community-Based Care Team

Maryland

Healthy Howard - a county-wide health improvement initiative - supported the deployment of a community-based care team as part of a three-year pilot. The team consists of nurses and community health workers who conduct outreach to eligible patients and help them navigate services such as transportation and prescription drug refills. In June 2016, the program's ownership transitioned from Healthy Howard to Howard County General Hospital, but the model remains unchanged and continues to provide home-based care management to frequently hospitalized Howard County residents.
Partner Organizations	Howard County Health Department Howard County General Hospital Healthy Howard, Inc. Local Health Improvement Coalition The Horizon Foundation
Target Population	Patients who have experienced two or more hospital visits and two or more chronic conditions in one year
Care Team	Nurses, community health workers, program manager
Timeframe	2014 - present
Results/ Studies	IMPAQ International evaluation (2015)
Funding	Federal and private grants
Resources	Program website YouTube video - program overview