Connecting patients, doctors and service providers in Baltimore

A fledgling Baltimore effort tries to connect health care providers to the social services network to benefit

The social services network in Baltimore, as in many cities, is not consolidated or accessible as a whole. Health care providers and community health workers spend untold hours searching for, sorting and engaging needed social services for patients — and then have no way to monitor and assess their actual use by individuals.

It's a considerable problem. Social inequities significantly affect health outcomes. But requiring health care providers to focus on and reduce the disparities in health outcomes involves a reinvention of services offered. While providing insurance free of charge is a starting point, there is more to providing access to care than this. In addition to targeting and developing proper medical protocols, social service assistance and networking must more successfully be brought into play.

While some of the finest health care organizations in the world work hard in Baltimore to have a beneficial presence, they have not yet had quick and easy access to available community based social services from a consolidated service sector that is easily searchable, monitored, accessed and graded and is interactive and kept current. Searching and obtaining social services with the same ease that we order consumer products that are delivered to our door simply has not been possible — until now.

The convergence of health care reform efforts, the spotlight on disparities in health outcomes and the focus on social justice disparities, all paired with the advanced capabilities of today's technology brings us to the doorstep of a new era. Our community is indeed piecing together the next steps that are needed to gain access to and make effective use of the social services network in Baltimore.

Utilizing resources of Johns Hopkins Hospital; the University of Maryland Medical System; and Resource Partners, a health care technology consulting company, a non profit organization called The Medi was created. Late last year, The Medi launched a virtual Community Resource Center in Baltimore City at the University of Maryland BioPark, just at a time when many aspects of health disparities and social justice in Baltimore were being examined. Several Baltimore organizations are piloting the CRC, which acts as a support center using technology to coordinate care and community referrals.

Officials at the Baltimore City Health Department (BCHD) are evaluating the tool to consider including it in a submission to the Centers for Medicare and Medicaid Services "Accountable Health Communities" program, a competition in which $157 million will be awarded to 44 organizations nationwide that demonstrate an effective model to address these issues. If Baltimore's effort is selected, it will make the city a national model for integrating social services into the patient health care plan.

The convergence of these events has created a platform for Baltimore to do better. Changing people's lives for the better doesn't happen overnight. People have to participate too and change themselves. The Community Resource Center will allow health care and social service providers to get people what they need sooner, better and faster, and then people will do better too.

Sally Staehle is director of development for The Medi; her email is

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