Care Coordination

What We Do

  • We co-develop a training program for paraprofessional health workers to enhance Community Capacity to address unmet Social Needs.

  • Working together, we boost individuals’ capability to serve as community leaders and their confidence in collaborating with other participating organizations.

  • We strengthen organizational ties between community-based organizations and the local health system.

  • We strive to educate community health workers and health navigators about social and healthcare resources that patients and community-based organizations’ clients can access locally and be referred to.


  • Recruited individuals from Bea Gaddy Center, McElderry Park Community Association, Housing Upgrades to Benefit Seniors, After Care Clinic, Urban Health Residency Training Programs, and Departments of Social Work at Johns Hopkins Hospital to co-develop the training program.

  • We facilitated monthly workshops for the training program development, where participants discussed their experiences with what social needs their patients/clients face and identified questions for community health workers to understand ways to address those need.

  • We facilitated collection, prepared and distributed organization-individualized and overall results of the 2017 Community Health Needs Assessment filled by 269 clients of 10 Baltimore CONNECT network organizations.

  • Throughout 2013-2017, we conducted a multi-component intervention that included (a) an online tool to assist in the referral of clients to health and social service, (b) meet and greet sessions between our network organizations staff and health care staff, and (c) help of research assistants; the intervention led to an increase in the referrals and a significant reduction in barriers related to the lack of information about services our network provides collectively.

  • Baltimore CONNECT was mentioned in Robert Wood Johnson Foundation (RWJF) Culture of Health Sentinel Community Portrait report. The report noted that Baltimore CONNECT, " a strong connector organization", "helps expand the scope of [community-based] initiatives and “braid” funding available from federal, state, and local sources."