Baltimore Medical Systems
Program Name: Behavioral Health Informed Health Home Pilot
Grant Amount: $498,906/2 years
Baltimore Medical Systems, Inc. operates seven health centers and is the largest community health network in the state of Maryland. BMS provides primary care to Baltimore City and County and serves a multicultural patient base. The BMS program will be piloted at their largest clinic in the Highlandtown area of Baltimore City. The program design is to expand the BMS health home model to address unmet behavioral health needs of complex patients with out-of-control chronic conditions. This is an integrated behavioral health/ primary care model where the patient's primary care physician works with a care manager and psychiatrist to develop, implement, and modify (where necessary) treatment plans to promote better adherence to medications and follow-through on physician orders and to improve biomedical outcomes as measured by clinical indicators related to chronic conditions. A comprehensive clinical assessment will be conducted for every patient and a web-based care management tracking system with a registry function will be used in this project. Grant to fund care coordinators, project manager and data coordinator salaries, psychiatrist consultants and tech support.