Maryland Care Hub Selected for Federal Health at Home Initiative

The National Consortium of Community Care Hubs, led by the Oregon Wellness Network, emerged as one of ten winning teams selected by the U.S. Administration for Community Living. This initiative targets older adults and individuals with disabilities, focusing on reducing hospital readmissions and lowering costs through improved care transitions, nutrition services, and fall prevention programs.

TLC-MD serves as the anchor for the Maryland and D.C. market, integrating its existing community health infrastructure with Freedmen's Medicine’s home-based clinical expertise. The collaboration utilizes the AthenaOne electronic medical record platform, which incorporates artificial intelligence to identify high-risk patients and guide real-time interventions. This shared digital infrastructure allows the eight-hub consortium to coordinate care for more than 100,000 beneficiaries nationwide.

Margaret Fowler, executive director of TLC-MD, stated that the recognition provides a platform to expand current diabetes prevention efforts into a comprehensive support network. The model aligns with Maryland’s statewide cost-of-care framework, aiming to improve HEDIS quality measures by streamlining referrals from hospitals and primary care practices. As the project advances into its second phase, the consortium will continue implementing these services through July 2027, competing for a final selection in the project's scaling phase.