Statewide community care hub, in partnership with Freedmen’s Medicine, anchors Maryland and the District of Columbia in an eight-hub national consortium expanding in-home and community care for older adults on Medicare and Medicaid, powered by a shared electronic medical record with artificial intelligence
OWINGS, Md. , Oct. 6, 2026 /PRNewswire/ — Totally Linking Care in Maryland (TLC-MD) has been named part of a winning team in the federal Health at Home Challenge, a national competition run by the Administration for Community Living within the U.S. Department of Health and Human Services. The National Consortium of Community Care Hubs for Health at Home — a network of eight community care hubs spanning eight states, led by the Oregon Wellness Network, with physician-owned CCH Medical Group as its healthcare partner — was one of ten winning teams selected nationwide. TLC-MD anchors the consortium’s statewide Maryland and Washington, D.C. market, in partnership with Freedmen’s Medicine, a Washington, D.C.-based primary care practice specializing in home-based care for adults with chronic conditions.
The Challenge is designed to help older adults and people with disabilities who are covered by both Medicare and Medicaid stay healthy and independent at home — reducing hospital stays and lowering the total cost of care. Winning teams were chosen for their ability to deliver navigation, care coordination, care transitions, evidence-based health promotion programs such as fall prevention, and nutrition services at large scale. Maryland was among the geographic areas of interest identified by the Administration for Community Living for the Challenge.
The consortium’s eight community care hubs and their markets are: the Oregon Wellness Network (statewide Oregon, lead hub); SARCOA / Community Care Solutions (southern Alabama and the Florida Panhandle); CATCH Greater Houston and the Houston Health Department (greater Houston); the Western New York Integrated Care Collaborative (Western New York); TLC-MD (statewide Maryland and Washington, D.C.); the Piedmont Triad Regional Council Area Agency on Aging (North Carolina); and the Region IV Area Agency on Aging (southwest Michigan). Together, the hubs aim to serve more than 100,000 Medicare and Medicaid beneficiaries with chronic conditions.
What This Means for Maryland and the District of Columbia
For residents of Maryland and the District of Columbia, the win accelerates a model TLC-MD has been building statewide: a trusted network of community-based organizations connected directly to the healthcare system. As a CDC-recognized Umbrella Hub for the National Diabetes Prevention Program, TLC-MD already organizes community organizations across the state to deliver evidence-based chronic disease prevention — infrastructure the Challenge will now extend to a broader set of services. Through its partnership with Freedmen’s Medicine, a Washington, D.C.-based practice delivering physician-led, home-based primary care to homebound adults with chronic conditions and behavioral health needs, the market pairs TLC-MD community network with in-home clinical care for the region’s highest-need residents. Older adults will see expanded help getting home safely after a hospital or nursing facility stay, care plans supported by nurses and community health workers, evidence-based fall prevention classes and diabetes prevention programs in their communities, and home-delivered nutrition support — from Baltimore and the District of Columbia to the Washington suburbs, the Eastern Shore, and Western Maryland.
The model is a natural fit for Maryland, where the state’s nation-leading total cost of care framework already aligns hospitals and the healthcare system around keeping people healthy in their communities. TLC-MD and Freedmen’s Medicine will collaborate directly with local health systems, accountable care organizations, and managed care plans across Maryland and the District of Columbia to expand these innovative care models, with the goal of improving clinical outcomes and reducing the total cost of care. Expected results include more healthy days at home for residents and improved performance on HEDIS, the quality measures health plans use nationwide to track how well care works.
Residents will be connected to services through referrals from local hospitals, primary care practices, and health plans across five care pathways: hospital-to-home transitions, primary care and ACO referrals, nursing home-to-community transitions, fall prevention, and depression and social isolation support delivered through collaborative care.
One Shared Record, Smarter Care
Through the national consortium, all eight member hubs operate on a single shared AthenaOne electronic medical record — a first for community-based care at this scale — with integrated artificial intelligence for population health analytics. The AI-supported platform helps care teams identify at-risk individuals earlier, guide community health workers in real time, and measure what matters most: more days at home and lower cost of care.
“This national recognition gives TLC-MD an opportunity to build on what we already know works—connecting trusted community organizations directly to healthcare. We can now take the infrastructure we have built through diabetes prevention and expand it into a broader network that helps older adults safely transition home, better manage chronic conditions, and access the services and supports they need to live healthier, more independent lives in their own homes and communities.”” said Margaret Fowler, Executive Director, TLC-MD.
The team now advances to Phase 2 of the Challenge (August 2026 – July 2027), implementing its strategy across Maryland, the District of Columbia, and nationally. Up to five teams will be selected in summer 2027 to advance to the final scaling phase.
About TLC-Maryland
TLC-MD is a nonprofit coalition of 5 hospitals that connects healthcare providers and programs with residents in Maryland. We build innovative health programs by breaking down barriers to health care services and building bridges between hospitals, healthcare professionals, community-based organizations, and, most importantly, the residents of our community.
About Freedmen’s Medicine
Freedmen’s Medicine is a Washington, D.C.-based primary care practice delivering physician-led, home-based medical care to homebound adults living with chronic conditions and co-occurring behavioral health needs. Through its partnership with TLC-MD, Freedmen’s Medicine extends the consortium’s community care model to the District of Columbia.
The Health at Home Challenge is administered by the Administration for Community Living. This announcement does not imply endorsement by ACL, HHS, or the federal government.
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SOURCE TLC-Maryland
