Howard County General Hospital (HCGH) has announced the launch of a population health strategy to improve the health and wellness of county residents. The initiative has been designed to address community needs in chronic disease management, behavioral health and access to care that have been identified through a detailed evaluation, and analysis of the gaps and needs of county residents.

HCGH developed the model in collaboration with the Howard County Health Department, the Horizon Foundation and members of the Local Health Improvement Coalition, as well as local primary care and specialty practices, among other partners.

The centerpiece of the initiative is the Howard Health Partnership (HHP), a framework of programs that are designed to improve health and reduce costs for Medicare-eligible residents, and those dually eligible for Medicare and Medicaid, who have chronic conditions that have led to multiple, potentially preventable hospital stays.

HCGH has received a $1.47 million grant from the Maryland Health Services Cost Review Commission to help implement the HHP. Additionally, the health department is providing funding to HCGH to deliver other components of the broader strategy, and the Horizon Foundation has also granted financial support to jump-start program implementation.

The HHP framework includes programs in three areas.

  • Intensive care management for complex patients with multiple chronic conditions.
  • Improving transitions from one care setting to another and into the community.
  • Supporting care management for patients and their caregivers.

Each area contains specially tailored programs, including a multi-disciplinary community care team that helps address clinical and social issues; a Rapid Access Program for behavioral health patients; home medical visits for frail elderly and classes designed specifically for caregivers. The strategy includes a faith-based component called Journey to Better Health, also funded by the health department.

The hospital is leading the comprehensive community effort to provide patient-focused services in collaboration with local providers and agencies, including the health department and Office on Aging and Independence, Lorien Health Systems, Johns Hopkins Home Care Group, Gilchrist Services and Way Station.

“We have created an infrastructure to deliver a comprehensive and effective program that addresses the needs of our target population and positions the Howard Health Partnership to contribute to improving overall health and well-being for all county residents,” said Elizabeth Edsall Kromm, vice president of population health and advancement at HCGH. “Simply put, we know how to work together to achieve ambitious health goals.”

The population health model is being launched as Howard County’s population grows older and unique demands arise. Projections show that, by 2035, 38% of Howard County residents will be ages 50 and older.