Care Coordination | BHB Website

Care Coordination

Care Coordination is the backbone of B’more for Healthy Babies’ (BHB) citywide strategy to strengthen Baltimore’s maternal and child health (MCH) system.

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Overview

Care Coordination is a system that helps families access the health care and community services they need by connecting them to the right programs at the right time. It organizes resources across Baltimore’s MCH system, linking families to services like home visiting, prenatal and pediatric care, behavioral health, and supports for housing or nutrition. The care coordination workforce includes community health workers (CHWs), social workers, and nurses trained in trauma-informed care. Visit SAMHSA’s Trauma-Informed Approaches and Programs page to learn more about how to train staff and implement these practices.

Care Coordination works by assessing each family’s needs, providing personalized outreach, and guiding them through referrals to services, so they don’t have to navigate the system alone. This ensures families receive the appropriate level of support, from general education to intensive one-on-one care, using limited resources efficiently.

Baltimore has had Medicaid Administrative Care Coordination since the 1990s, linking families to health care and community resources. The catalyst for today’s enhanced system was the need for a single, centralized intake and referral process to connect families to Baltimore’s network of evidence-based home visiting programs (HVPs). This approach then expanded across the entire MCH continuum from prenatal care through age 3.

BHB's Approach

Baltimore used local data—including self-reported client information, vital statistics, Geographic Information System (GIS) mapping, and neighborhood profiles—to understand community needs and identify where services and funding would make the biggest difference. Just as important was investing in a trained care coordination workforce able to meet families where they are, conduct outreach and assessments, locate families traditional outreach misses, and link them to health care, behavioral health, early childhood programs, and resources addressing social determinants of health.

This data-driven and workforce-centered approach, highlighted in the Pew Charitable Trusts’ Bringing Up Baltimore report, transformed a set of disconnected services into an integrated citywide care coordination system.

Families enter care coordination through three referral pathways: self-referrals, referrals from community organizations, and referrals from health care providers. These pathways all lead into one centralized intake and coordination system managed by the Administrative Care Coordination Unit (ACCU) at HealthCare Access Maryland (HCAM), a quasi-public agency that connects families to Medicaid and other vital services.

BHB’s “no wrong door” approach builds trust, strengthens connections, and reduces duplication of services.

This approach is anchored in BHB’s Population Health Pyramid framework, which illustrates a continuum of services ranging from broad population-level interventions to more intensive, individualized supports such as home visiting programs for families with the greatest needs.

The framework applies both citywide and at the neighborhood level, and these levels must stay connected to effectively reach families. The pyramid reminds us not to concentrate all resources solely on intensive individual care but to work across all levels to maximize impact and ensure families receive the right support at the right time.

Care Coordination Versus MCH Systems

It is important to distinguish between the maternal and child health (MCH) system of services and the care coordination system. The MCH system includes programs like home visiting, group-based education, early intervention, and the USDA Women, Infants, and Children program (WIC). Care coordination is the mechanism through which pregnant women and families are linked into this system. It involves outreach, assessments, and referral to services.

The centralized intake system serves as the single point of entry – through referrals from Prenatal Risk Assessments (PRAs), Postpartum Infant and Maternal Referrals (PIMRs), self-referrals, and community outreach efforts – and helps ensure families receive care coordination services. This system also coordinates data sharing and enrollment information between HCAM and home visiting programs to reduce duplication and improve efficiency.

The coordinated system uses braided funding streams—including Medicaid, Title V and Title X block grants, major federal MCH grants, WIC, the Baltimore Infants & Toddlers Program (BITP) from the Maryland Department of Education, and local and state general funds—allowing local health departments to leverage Medicaid matching dollars and optimize every public dollar for maximum community impact.

This robust system was built through close partnerships among the Baltimore City Health Department, HCAM’s Administrative Care Coordination Unit, evidence-based home visiting programs launched through a clear citywide strategy guided by the Local Health Department, trusted community organizations, Judy Centers (Maryland’s community-based early learning and family support hubs), neighborhood-based Community Health Advocates, and managed care organizations. These partners collaborate to share data, align funding, and meet families where they are.

Developing a System for Care Coordination

Not every city has a dedicated care coordination unit, but this mechanism helps communities access public funding and sustain services over time. Building and maintaining a trusted care coordination system requires ongoing effort—especially early on as partners align systems, data, and referral processes.

Many states, including Maryland, use the Prenatal Risk Assessment (PRA) for Medicaid patients as a foundational tool to identify pregnant women at risk and trigger care coordination services. Communities can also explore other systems with high contact rates among pregnant women to maximize reach.

B’more for Healthy Babies (BHB) has developed a system that supports families and the broader ecosystem with Coordinated Services and Supports and System Strategies to Strengthen Care Coordination.

Coordinated Services and Supports

Offering referrals to proven services such as home visiting, prenatal and pediatric care, Medicaid, WIC, income supports, and resources addressing social determinants of health like housing, literacy, and job training.
Navigating families through multiple referrals while building trust and reducing barriers to participation.
Connecting families to behavioral health services, including mental health care and substance use treatment.
Sharing targeted health education and parenting support shaped by local data and community input, covering topics such as smoking cessation, dental care during pregnancy, and safe sleep.
Addressing maternal hypertension, chronic disease management, family planning, and interconception care.

System Strategies to Strengthen Care Coordination

Prioritizing families with the greatest need so limited resources, like home visiting slots, are used where they can have the most impact. BHB uses tools to triage pregnant women into home visiting programs based on level of need.
Reducing duplication, aligning community resources, and strengthening cost-effective collaboration across programs. For example, BHB’s home visiting collaborative, BabyStat, conducts quality improvement by sharing referral outcomes and enrollment data to improve enrollment rates and resolve bottlenecks.

BHB actively engages with people facing barriers through B’more Beginnings, a direct marketing program that helps make the complexities of care coordination more accessible and helps to increase self-referrals. BHB also connects families to a community health advocate workforce embedded in neighborhoods who use creative outreach strategies, and braided non-Medicaid funding that allows cases to stay open instead of closing due to lost follow-up.

Through a combination of telephone outreach and community home visits, outreach staff use referrals as a tool to provide individualize education that blends their knowledge of the Medicaid benefit system with available resources to address medical, social and behavioral risk. An electronic database tracks referrals, outcomes, and service coordination to support data-driven improvements.

By improving access and equity, care coordination helps ensure that more families receive the right support at the right time while reinforcing the entire maternal and child health system. Communities considering care coordination can start with existing resources, such as the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program, a vision for sustainability in resource-scarce environments, or a commitment to expanding beyond individual programs to achieve population-level change.

Recommendations

These recommendations are rooted in what has worked in Baltimore and reflect lessons learned from on-the-ground experience. They offer a practical roadmap for other communities looking to strengthen maternal and child health (MCH) systems through Care Coordination that bridges providers, health insurance, and community partners.

Align partners and share data around a common goal.

BHB’s success grew from a clear goal, a citywide commitment to reduce infant mortality and racial disparities. Local leaders rallied partners around this cause, built shared data systems, and used the numbers to keep the work focused and improving over time.

Identify a clear goal that partners can stand behind and create ways to share data to stay on track together.

Bring care coordination into trusted community spaces.

Some Community Health Advocates work out of Judy Centers, WIC sites, and neighborhood organizations where families already feel welcome. That makes it easier to build relationships, provide real-time support, and reach families who may not engage in traditional clinical settings.

Think about how you can embed care coordination where families already go for support, not just in clinical settings.

Make it easy for families to reach out directly.

Families don’t need a provider referral to access care coordination. BHB offers a public phone line, online referral form, and multiple entry points so people can connect on their own terms.

Create clear, simple ways for families to self-refer—especially if they’re not already connected to a provider.

Take time to identify and document existing resources

BHB blends Medicaid dollars with federal block grants, Title X, Title V, WIC, Department of Education Early Intervention funds, and local and federal general funds. By tracking and bundling these streams, local health departments can leverage Medicaid matching funds and make the best use of every public dollar. This “braided funding” approach helps fill gaps, add supports like safe sleep supplies, and hire trusted community staff.

Start with a detailed map of your referral network—so your system doesn’t just work in theory, but in practice.

Braid funding to make the system more responsive.

BHB blends Medicaid dollars with federal block grants,
Title X, Title V, WIC, Department of Education
Early Intervention funds, and local and federal
general funds. By tracking and bundling these streams,
local health departments can leverage Medicaid matching funds and make the best use of every public dollar. This “braided funding” approach helps fill gaps, add supports like safe sleep supplies, and hire trusted community staff.

Look for ways to layer funding streams so your system can meet families’ real needs—even when one stream falls short. This work will be ongoing throughout the initiative as funding opportunities shift and change.

Build strong partnerships with providers.

BHB positions care coordination as a bridge connecting families, providers, and health insurance plans. They meet regularly with OB/GYNs, pediatricians, and MCOs to align referrals, share data, and improve workflows.

Meet providers where they are, and co-create referral processes that fit their daily workflows.

Use data to focus on what matters most.

Data from fatality reviews like Fetal and Infant Mortality Review,Maternal Mortality Review, and Child Fatality Review helped us zero in on safe sleep and financial stress. That led to practical interventions—like giving out cribs and connecting families to free tax prep for the Earned Income Tax Credit.

Use your local data to identify priority issues—and make sure your interventions address them directly.

Treat each outreach as the start of a relationship.

Our care coordinators explain what to expect, follow up, and take time to build trust. That personal connection helps families feel seen—and supported.

Don’t just pass along information. Create space for connection, clarity, and care.

Strategies and Results

BHB uses Care Coordination as a bridge that connects families, healthcare providers, health insurance, and trusted neighborhood organizations—pulling people into the healthcare system and creating a network of communication and support. These strategies reflect how the system operates and the results that show its impact.

Centralized Intake System

BHB established a single, accessible point of entry for pregnant and postpartum women across Baltimore. This system especially supports those uninsured or enrolled in Medicaid, with multiple referral pathways including provider referrals, community outreach, and self-referral. It enables timely health and needs assessments, short-term support, and coordinated referrals to a broad spectrum of services.

Result(s):

Families connected through this system were 80% more likely to have infants survive their first year.
The system supports over 5,000 pregnant and postpartum women annually and engages more than 12,000 individuals through the city’s Medicaid coordination infrastructure.

Data-Informed Triage to High-Impact Services

A standardized triage process uses data from self-reports, provider assessments, and public health data to make sure people with the greatest needs are prioritized for services with limited capacity, such as evidence-based home visiting programs. This strategy moves away from first-come, first-served models toward equitable access based on risk and need.

Result(s):

More high-risk families are connected to the services proven to improve birth outcomes, reducing preventable disparities.

Community-Based Coordinators

Community Health Advocates (CHAs) and neighborhood-based coordinators meet families where they are, build trust, and provide hands-on help navigating complex systems. Hiring from the community helps bridge gaps between the healthcare system and neighborhoods, making services more trusted and accessible.

Result(s):

CHAs achieved a high rate of successful client contact (reducing ‘unable to locate’ referrals, which often reflect families who are the most marginalized and least trusting of the system), helping ensure families receive the care they need.
In-person support through community hubs like the Judy Centers enabled responsive services and addressed immediate needs.
Clients referred through the community hubs also showed lower rates of low birthweight deliveries.

Targeted Health Education

BHB uses community data to guide outreach and education. Coordinators deliver targeted messages on topics like safe sleep, smoking cessation, and maternal oral health—tailored to the trends and needs of local neighborhoods.

Result(s):

Baltimore saw a 71% reduction in sleep-related infant deaths, supported by safe sleep education and crib delivery through the care coordination system.

Cross-Sector Collaboration

BHB collaborates with healthcare providers, home visiting programs, and government agencies to align services, strengthen referral pathways, and reduce duplication. A key focus is partnering with obstetric clinics to complete PRAs in electronic format and increase participation in care coordination. This partnership effort has shifted approximately 70% of obstetric providers in the city to actively connect patients to the system.

Result(s):

Since BHB’s launch in 2009 through 2022, Baltimore City’s infant mortality rate declined by 44%, while the Black-White disparity in infant mortality decreased by 49%.