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For many years, GBMC Health Partners patient-centered medical homes (PCMHs) throughout Baltimore and Harford counties have provided advanced primary care services focused on building relationships, managing chronic conditions, and keeping patients healthy and out of the hospital. This innovative team-based approach to keeping patients well costs more than traditional primary care, and doctors see fewer patients in a day, but GBMC is confident in using this approach because comprehensive services free of time constraints are proven to result in better health outcomes.

GBMC HealthCare has recently made this successful model of care more accessible to underserved populations in Baltimore City, whose mortality rate is 40% higher than the rest of the state.

In February 2022, GBMC HealthCare received the Maryland Community Health Resources Commission (CHRC) Pathways to Health Equity grant.* Through the grant, GBMC partners with several community organizations to focus on medically underserved communities in Baltimore City with the goals of addressing social determinants of health, achieving equitable access to healthcare, and reducing health disparities.

This approaches promises “HealthCare Made Easy: In Your Neighborhood. In Your Home.” The “in your neighborhood” component refers to the GBMC Health Partners Primary Care—Jonestown practice, centrally located in Baltimore City. Like GBMC’s county practices, Jonestown ensures coordinated care and a one-stop-shop for lab work, preventive care, screenings, vaccines, and primary care.

GBMC has removed transportation as a barrier to care by providing complimentary private rides to and from the Jonestown practice via Lyft for any Baltimore City residents who state they lack reliable, safe transport. Rides are facilitated by a GBMC care coordinator, so patients do not need access to a cell phone to use the service.

The “in your home” component refers to the Gilchrist Elder Medical Care (EMC) program. For seniors who are too frail or sick to leave their homes, Gilchrist addresses access issues by bringing primary care directly into residents’ homes, offering medications, labs, X-rays, symptom management, and emotional support. EMC patients also have access to a 24/7 nurse support line for questions.

Once an individual becomes a primary care patient at Jonestown or through the EMC program, they can connect with other resources to access the quality healthcare they need. These could be specialists like our integrated behavioral health consultants, medication delivery, or connections with community partners to help navigate challenges associated with insurance, access to fresh groceries, fitness programs, legal support, and more.

By improving access to medical care and lifestyle resources, GBMC and its many community partners are reducing barriers to achieving better health and addressing chronic diseases such as diabetes, hypertension, and obesity that contribute to preventable hospital visits and shortened life expectancy.

Even in the short time since obtaining the grant and implementing services, GBMC is seeing success and improved health metrics in the patients it is serving. One of the goals developed upon opening the practice was to reduce the percentage of Jonestown patients with uncontrolled diabetes, defined by having an A1C level lower than 9%.

The work toward this goal is based on the principles of building relationships and committing to being accountable with patients. Members of the Jonestown team partner with patients, checking in between visits to ensure they have insulin and are monitoring their glucose levels as prescribed.

There is exciting evidence that the approach is working: Since beginning this initiative, the percentage of GBMC Jonestown patients with uncontrolled diabetes has been reduced by almost half.

Work is underway to pursue more funding from the Maryland CHRC to answer their call for proposals to become a Health Equity Resource Community (HERC). Funding is available from the Maryland Health Equity Resource Act to build on our work at GBMC Health Partners Primary Care – Jonestown and EMC program. The EMC program recently expanded to serve more individuals in Baltimore City with the aim of further reducing health disparities and improving health outcomes in underserved communities. That grant will be completed and submitted in early December.

*This program is funded in part by the Maryland General Assembly as part of the Maryland Health Equity Resource Act. Grant funding is administered by the Maryland Community Health Resources Commission. For more information, please visit: https://health.maryland.gov/mchrc/Pages/herc.aspx. The views presented here are those of the grantee organization and not necessarily those of the Commission, its commissioners, or its staff.

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