"Part of it is a cultural issue of thinking the ED is the best or most convenient place to receive care, and part of it is letting chronic diseases escalate to the point where they become an acute illness and need emergency treatment. There are also a lot of social determinants that we are looking to address, whether it is access to healthy food, or access to safe recreational fitness facilities. West Baltimore does not have a lot of assets in this regard at this point and what we want to do is turn the focus on that."
The West Baltimore HEZ will focus on coordinating care through patient-centered medical homes. Outreach and education will be spearheaded by community health workers who will be deployed across the four zip codes in the zone to speak on topics that include disease management, fitness and nutrition, while ensuring that the residents they meet have access to primary care.
"A big component of this is the strengthening and development of the patient-centered medical home model with a large focus on care coordination across all of our collaborative sites—making sure patients are having handoffs from one entity to the next, from one clinic to a doctor, or community based organization that can help meet social needs," Kearns says.
"That is really the approach we are looking at, which is let's build an infrastructure that allows for care coordination, but also builds that structure that allows for common delivery of education and outreach and then strengthen the existing base so that we are working better together."