Care Coordination Impact

Healthy Howard’s Community Care Team takes a focused, innovative approach to improve the health of frequently hospitalized Howard County residents. This new program helps chronically ill individuals connect with resources that allow them to better manage their illness, improve their health and avoid preventable hospitalizations.

More than 70 individuals have benefited from the Community Care Team’s support in the program’s first year. A recent evaluation found that the Community Care Team has had a positive impact on participants. In a survey of individuals who successfully completed the program’s 90-day support process, 63 percent reported feeling in control of their health and well-being “most of the time” or “all the time” compared to 48 percent at enrollment. The proportion of clients who indicated being comfortable navigating the health care system also increased from 37 percent at enrollment to 56 percent upon graduation from the program.

One client empowered by the program is a 63-year-old female who had been diagnosed with chronic obstructive pulmonary disease, diabetes, heart disease and neuropathy. Prior to the intervention by the Community Care Team (CCT), she was hospitalized three times in six months.

Despite these repeated hospitalizations, she had not followed up with a primary care physician or specialists in over a year due to mobility issues. But the CCT got her to agree to use a new transportation service, resulting in two follow-ups with her primary care physician and visits to a cardiologist and podiatrist.

The client’s primary source of support, a sister, was often absent and unavailable to provide assistance during the day. This caused the client to miss medical appointments and delay medication refills because she could not get to the pharmacy before closing. A community health worker from the Community Care Team connected her with medication delivery services and transportation for medical appointments. Now she is able to schedule her own appointments and transportation and obtain medication refills without the assistance of her sister.

The client also did not have the proper medical equipment to monitor her blood glucose and blood pressure. Our team’s community health worker helped her obtain a working glucometer, test strips and blood pressure equipment. The client is now tracking both her glucose levels and blood pressure daily, which have helped regulate her diabetes and her heart disease. She has not been hospitalized since she began working with the CCT three months ago and will graduate from the program soon.

Learn more about Healthy Howard’s Community Care Team program.