Grantee Organization: MedStar Franklin Square Hospital
Focus Area: Diabetes/Food Security; Primary Care; Behavioral Health
Grant and Amount: 23-001 ($290,000)
Grant Project Description: The program is addressing disparities in chronic disease, food access and other disparities being faced by African-American residents of Baltimore City and Baltimore County. MedStar Franklin Square Hospital is providing healthy food to patients so they can prepare nutritious meals for their families, connecting patients to a dietician and Community Health Advocate, and providing 20 hours of health education. The Primary Care Center and Family Health Center allows patients to access primary care, specialty care, preventive services, and behavioral health assistance.
Grantee Organization: Asian American Healthcare Center
Focus Area: Primary Care; Promoting Care in the Community
Grant and Amount: 23-005 ($160,000)
Grant Project Description: The program is addressing disparities in cardiovascular disease among low income and/or vulnerable Asian-American residents in Baltimore County, Baltimore City, and Howard County. Grantee is offering one-stop comprehensive screenings (including EKG, A1c, cholesterol panel, lung disease screens) and a physician consultation to review test results, diagnoses, and medications, as well as referrals to primary or specialty care. In addition, care coordination services related to medication management and referrals for wraparound social and community services will be offered, as well as culturally and linguistically appropriate health education and health coaching.
Grantee Organization: Shepherd's Clinic
Focus Area: Diabetes; Promoting Care in the Community
Grant and Amount: 23-006 ($280,000)
Grant Project Description: The “TRIUMPH" program is addressing racial disparities related to diabetes among uninsured and underinsured adults in Baltimore City. Through the “TRIUMPH" program, grantee is providing: (1) education on healthy eating and nutrition counseling by a licensed dietician; (2) expanded access to movement classes; (3) remote patient monitoring for weight, physical activity, and blood glucose; and 4) navigation to services that address other patient needs.
Grantee Organization: Associated Catholic Charities – Esperanza Center
Focus Area: Diabetes; Primary Care
Grant and Amount: 23-007 ($115,000)
Grant Project Description: The program is expanding access to effective screening and diagnostic testing for diabetes, high blood pressure, and high cholesterol for the uninsured Latino immigrant population in Baltimore City and Baltimore County. The Esperanza Center is providing clients with point of care phlebotomy and screening services, focusing on screening and management of chronic diseases.
Grantee Organization: Health Care for the Homeless
Focus Area: Diabetes/Food Security; Reducing Avoidable ED Visits
Grant and Amount: 23-008 ($390,000)
Grant Project Description: The program is expanding access to care for unhoused and housing insecure individuals, particularly racial and ethnic minorities, who are living in Baltimore City and impacted by diabetes, hypertension, heart disease, and comorbidities. The program is providing comprehensive care management to engage participants, implement interventions to control high blood pressure and diabetes, routinely measure BMI for management, and complete follow up planning after emergency department admissions and acute hospitalization.
Grantee Organization: Baltimore Medical System
Focus Area: Dental
Grant and Amount: 23-011 ($745,000)
Grant Project Description: The program is expanding access to dental services for low-income residents in an area that is underserved when it comes to medical, mental health, and dental services. Grant funding is allowing grantee to launch a dental program at their Yard 56 FQHC site and create an integrated center for medical, behavioral health, and dental services.
Grantee Organization: Lighthouse, Inc.
Focus Area: Behavioral Health
Grant and Amount: 23-015 ($155,000)
Grant Project Description: The program is expanding counseling and other services for families in Central Maryland affected by a loved one's substance use. The program is helping grantee's clients improve their mental health; increase their life satisfaction; strengthen family bonds; increase knowledge about addiction; improve coping strategies and stress management skills within families, schools, workplaces, and the community; decrease substance use by children served by the project; and increase awareness of and treatment options for families affected by opioid use.
Grantee Organization: Grassroots Crisis Intervention Center
Focus Area: Behavioral Health
Grant and Amount: 23-016 ($500,000)
Grant Project Description: The program is adding 24-hour behavioral health urgent care services to grantee's existing SUD crisis stabilization services in Central Maryland. The program is focusing on residents in the service area who are low-income, African American, and/or women. Grant funding is allowing grantee to reduce barriers to accessing affordable, quality urgent behavioral health care; decrease the acuity of behavioral health symptoms; and decrease hospital emergency department visits for behavioral health patients.
Grantee Organization: Pride Center of Maryland
Focus Area: Behavioral Health
Grant and Amount: 23-017 ($875,000)
Grant Project Description: The program is increasing access to behavioral health care and somatic health care that improves mental health and decrease substance use, increase employment, increase housing stability, and decrease rates of overdose morbidity and mortality. Grantee's client population is a diverse mix of sexual and gender minority (SGM) individuals affected by adverse social determinants of health (SDOH), with an emphasis on African-American SGM, who face high rates of health disparities and adverse and disproportionate impacts from COVID-19.
Grantee Organization: Baltimore City Health Department
Focus Area: Women's Health Services/Infant Mortality
Grant and Amount: 23-021 ($500,000)
Grant Project Description: The program is expanding the capacity of the grantee's existing centralized intake system for pregnant women with a “no wrong door" marketing approach. Grant funding is allowing grantee to improve access and provider referrals, and supporting a new pilot for expanded care coordination that equips a Healthcare Access Maryland Community Health Advocate to follow up with clients and ensure that referred care and services are received.
Grantee Organization: Baltimore Healthy Start
Focus Area: Women's Health Services/Infant Mortality; Behavioral Health
Grant and Amount: PW 22-03 ($875,000)
Grant Project Description: This project is addressing disparities in hypertension, substance use disorder (SUD), low birth weight, and severe maternal morbidity for pregnant and postpartum women and their infants in the Druid Heights and Walbrook areas of Baltimore City. The project is expanding existing service coordination and home-visiting projects while making referrals to primary care and substance use treatment. Interventions include hypertension education administered by trained CHWs, home BP monitoring and tracking, peer support groups, and care coordination addressing clients' acute stressors and SDOH needs.
Grantee Organization: Greater Baltimore Medical Center
Focus Area: Diabetes; Primary Care; Promoting Care in the Community
Grant and Amount: PW 22-06 ($1,500,000)
Grant Project Description: This project is addressing disparities in diabetes and hypertension among the African-American population in the Greenmount East, Harbor East/Little Italy, Inner Harbor/Federal Hill, Midtown, Oldtown/Middle East, and Waverly areas of Baltimore. Key interventions include an expansion of the number of patients treated at GBMC's Jonestown Clinic, where patients receive comprehensive primary and preventive care services including vaccinations and screenings; disease management and care coordination services; at-home care for elderly participants; and support for SDOH needs. The project is also conducting public screenings and education at community events, as well as healthy lifestyle interventions such as community walks and runs, education workshops, patient support groups, peer challenges to support water and protein intake goals, and healthy cooking demonstrations.
Grantee Organization: University of Maryland School of Nursing
Focus Area: Promoting Care in the Community
Grant and Amount: PW 22-09 ($2,400,000)
Grant Project Description: This project is addressing disparities in hypertension, mental health, and social isolation in West Baltimore. Key interventions include establishing a learning collaborative, using nurse-managed health centers, leveraging mobile health care, and enhancing care coordination through a community health worker model. Targeted outcomes include decreasing the number of patients with uncontrolled hypertension and increasing participation in social support groups.
Grantee Organization: Sinai Hospital
Focus Area: Diabetes/Food Security; Behavioral Health
Grant and Amount: 22-01 ($360,000)
Grant Project Description: The project is addressing disproportionately high rates of diabetes, heart disease and hypertension, and the disproportionate impact of COVID-19 among Black residents in northwest Baltimore. Two Community Health Workers (CHWs) were hired to work at the LifeBridge Center for Hope and the Sinai Hospital Addictions Recovery Program (SHARP) and support the mobile health unit. CHWs and peer recovery specialists are screening individuals for somatic and behavioral conditions, providing linkages to care and wraparound services, and delivering case management services, including one-on-one wellness planning.
Grantee Organization: Sinai Hospital
Focus Area: Promoting Care in the Community
Grant and Amount: 22-02 ($350,000)
Grant Project Description: The EMPOWER project is working to control hypertension and prevent cardiovascular complications among Black residents of Baltimore City who have a higher comparative rate of uncontrolled hypertension. Interventions include utilizing remote patient monitoring, training and diversifying the care team, expanding current SDOH resources, and deploying CHWs for community blood pressure screenings. Community hypertension education is being provided, and patients are being offered wellness services such as yoga/meditation classes, nutrition counseling, cooking demonstrations, and gardening tips. The project is addressing social determinants of health (SDOH) needs, including food security, transportation, health literacy education, and language services.
Grantee Organization: Helping Up Mission
Focus Area: Behavioral Health
Grant and Amount: 22-09 ($285,000)
Grant Project Description: This project is expanding access to substance use disorder (SUD) and mental health services of individuals experiencing homelessness in Baltimore City and surrounding areas. Key interventions include using of a converted school bus and intake van to conduct street outreach for residential SUD programs, casework, and other referrals.
Grantee Organization: Baltimore Medical Systems
Focus Area: Behavioral Health
Grant and Amount: 22-10 ($500,000)
Grant Project Description: This project is expanding access to SUD treatment with an emphasis on opioid treatment for residents of Baltimore City and Baltimore County, particularly among their Black populations. Key interventions include a referral programs for obstetric patients and emergency department utilizers experiencing SUD or at elevated risk of relapse, enhanced capacity for SUD treatment, expanded SDOH screenings and interventions using the PRAPARE tool, and the provision of harm reduction trainings and materials.
Grantee Organization: Park West
Focus Area: Behavioral Health
Grant and Amount: 22-11 ($350,000)
Grant Project Description: This project is expanding access to behavioral health care and addressing adverse childhood experiences (ACES) among African-American youth and adolescents in the Park Heights neighborhood of northwest Baltimore. Key interventions include launching the “Psychiatric Rehabilitation Program" (PRP), expanded SUD services to include prevention and intervention outpatient services targeting youth and adolescents, and training staff on trauma-informed health care delivery.
Grantee Organization: Health Care Access Maryland
Focus Area: Women's Health Services/Infant Mortality; Diabetes/Food Security; Promoting Care in he Community
Grant and Amount: 22-12 ($560,000)
Grant Project Description: The project is addressing health disparities among low-income and at-risk mothers in Baltimore City. The project is employing a team of CHWs who receive referrals from Mercy Medical Center and provide care coordination for women experiencing hypertension, preeclampsia, and diabetes up to 90-days post-partum. The CHWs also connect women to primary care and community-based services and provide health education services, health insurance literacy, disease management services, and other post-partum services.
Grantee Organization: Chase Brexton
Focus Area: Women's Health Services; Behavioral Health; Promoting Care in the Community
Grant and Amount: 22-15 ($650,000)
Grant Project Description: This project is expanding Chase Brexton's capacity to provide prenatal and postpartum case management, care coordination, and psychosocial wraparound support for low-income women impacted by multiple SDOH. The program is focusing on racial and ethnic minorities, populations with limited English proficiency, uninsured and underinsured women, and low-income households. Chase Brexton is providing referrals to, and care coordination for, on- and off-site services, linkages to specialty care for high-risk patients, and referrals to community-based services, including WIC, to address SDOH.
Grantee Organization: Access Art
Focus Area: Promoting Care in the Community; Behavioral Health
Grant and Amount: 22-17 ($100,000)
Grant Project Description: This project is continuing grantee's food distribution events and comprehensive health services that address multiple SDOH in the Morrell Park neighborhood of southwest Baltimore. Grant funding is covering the salary costs for one CHW who assists families with accessing health insurance benefits, behavioral health services, and family assistance programs.
Grantee Organization: MedStar Good Samaritan
Focus Area: Diabetes/Food Security
Grant and Amount: 21-001 ($93,000)
Grant Project Description: The Good Samaritan Hospital Food Farmacy Program was designed for adult patients with Type 2 Diabetes who also may have been experiencing heart failure and/or food insecurity. Eligible patients received ongoing one-on-one care and consultations from a Community Health Advocate (CHA) and dietitian, and customized healthy food for making meals at no cost. The Good Samaritan Collaborative Care Center offered access to consultations, food storage capability and safe food pickup and delivery options to remove transportation barriers and increase access to care and food. The program also connected patients to holistic health resources in the community. The program served 136 participants over the course of the grant.
Grantee Organization: Baltimore Medical System
Focus Area: Diabetes/Food Security
Grant and Amount: 21-004 ($250,000)
Grant Project Description: This program supported the BMS DEAL program by covering the cost of a new Certified Diabetes Educator and Care Specialist (CDECS) to the multidisciplinary care team at the Saint Agnes and Pine Heights community health centers. The CDECS educated patients about diabetes self-management, helped them set behavioral goals to improve diet, and managed their weight to improve diabetic control and achieve better health outcomes. The CDECS also identified and addressed social barriers to accessing healthy food and complying with regular provider checks. The BMS DEAL is an integrated approach to diabetes care that facilitates access to a patient, provider, medical assistant, nurse, and/or pharmacist when necessary for patient education, testing, and follow-up. The two FQHC clinics also worked with several community partners to address food insecurity and transportation barriers. The DEAL Program served 292 patients over the course of the grant.
Grantee Organization: Associated Catholic Charities – Esperanza Center
Focus Area: Diabetes/Food Security
Grant and Amount: 21-007 ($125,000)
Grant Project Description: The “Diabetes and Dignidad" program employs a bilingual CHW to staff up to 70 community-based diabetes rapid A1c testing events every year for Latinx residents located in parts of Baltimore City, Baltimore County, and Anne Arundel County. Newly diagnosed diabetics who are uninsured and uninsurable are referred to Esperanza's primary care services and the Diabetes Self-Management Program (DSMP). Individuals diagnosed with prediabetes receive health information on managing the condition with a list of health care providers who can provide further screening. The CHW also provides diabetes self-management support, food security screening, and home visits to participants in Esperanza's existing DSMP.
Grantee Organization: University of Maryland - Baltimore
Focus Area: Diabetes/Food Security
Grant and Amount: 21-012 ($325,000)
Grant Project Description: This program boosted COVID vaccination among those engaged in the UMMS Family Medicine practice and residing in the surrounding community in downtown Baltimore. The program involved patient and physician education, a telehealth hotline, and two-dose COVID-19 vaccine delivery to the target population impacted by SDOH. The program engaged 3,431 adults and children during the course of the grant.
Grantee Organization: Baltimore City Health Department (BCHD)
Focus Area: Expanding Safety Net Capacity
Grant and Amount: 21-016 ($385,000)
Grant Project Description: This program supported increased access to preventative services at public health sexual health clinics by increasing STI and HIV testing in high-risk populations, providing at-home STI and HIV testing, and increasing referrals to pre-exposure peer navigators. Grant funding enabled BCHD to adjust clinic operations in response to the COVID-19 pandemic. The program targeted three groups disproportionately affected by both COVID-19 and STI/HIV: Black and Latinx individuals, individuals with lower socioeconomic status, and individuals with lower health care access. The program served 8,496 individuals over the course of the grant.
Grantee Organization: United Way of Central Maryland
Focus Area: Food Security
Grant and Amount: 21-017 ($93,000)
Grant Project Description: This program addressed food insecurity in Morrell Park, an underserved and impoverished community and known food desert in southwest Baltimore City, through a partnership with Access Art. Funding covered the salary cost of one FTE CHW and other costs, such as parent stipends, transportation, and nutrition classes. Access Art's weekly food distribution events will be transformed into comprehensive health markets that address multiple SDOH, with support from a bilingual CHW, to integrate health and social services. The CHW was also tasked with convening a team of residents and food experts to strategically plan how to increase the number of sustainable local food providers. The program served 1,952 individuals at weekly health markets over the course of the grant.
Grantee Organization: Jewish Community Services
Focus Area: Expanding Safety Net Capacity; Promoting Care in the Community
Grant and Amount: 21-018 ($153,000)
Grant Project Description: This grant expanded the Patient Care Connection Project, which works with private physicians to address their basic human needs, remove barriers to care, and address other SDOH affecting low-income seniors and individuals with disabilities. Funding increased the number of physicians participating to serve additional patients. The program served 434 patients over the course of the grant.
Grantee Organization: HealthCare Access Maryland (HCAM)
Focus Area: Expanding Safety Net Capacity
Grant and Amount: 21-019 ($430,000)
Grant Project Description: The grant expanded HCAM's existing program that enrolled incarcerated individuals into Medicaid prior to their discharge from the Baltimore City jail. Transition support was provided for up to 60 days to help individuals access primary and specialty care for chronic illness management, substance use treatment, housing and food access, and workforce development. The program targeted individuals who were over 59 years old and/or enrolled in chronic care clinics during incarceration, a population that was disproportionately impacted by COVID-19. The program served 352 individuals over the course of the grant.
Grantee Organization: Helping Up Mission (HUM)
Focus Area: Behavioral Health
Grant and Amount: 21-028 ($215,000)
Grant Project Description: The program supported expanded outreach to the Hispanic/Latinx populations impacted by COVID, screen for basic human needs, and/or enroll individuals with SUD treatment needs in a long-term residential “Spiritual Recovery Program." Funds covered the salary of a new bilingual Hispanic Outreach Coordinator (who is also a Certified Peer Recovery Specialist) and partially fund the salaries of current management staff. The program enrolled 168 Hispanic clients in HUM's “Spiritual Recovery Program" over the course of the grant.
Grantee Organization: Sinai Hospital
Focus Area: Expanding Safety Net Capacity;
Grant and Amount: 21-031 ($225,000)
Grant Project Description: The program supported a community mobile health clinic that provided health and social services to individuals in West Baltimore. The clinic served people of all ages by offering immunizations, chronic health management, and SDOH services. The mobile van included a CHW, nurse, and advance practice provider on its team. The mobile clinic served 271 individuals over the course of the grant.
Grantee Organization: Mosaic Community Services
Focus Area: Behavioral Health
Grant and Amount: 21-032 ($80,000)
Grant Project Description: This program provided internet-enabled tablets to facilitate psychiatric rehabilitative services for 200 adults with serious and persistent mental illness solely enrolled in grantee's “Psychiatric Rehabilitation Programs." It also supported the development of additional online psychiatric rehabilitation content and curriculum. Tablets provided clients with virtual access to daily psychiatric rehabilitation services; telehealth primary care and healthcare services; other virtual rehabilitative services such as music therapy; a Google Classroom with mental health rehabilitation resources and content; and the Sheppard Pratt YouTube channel. Clients were also provided with basic case management services, such as assistance with securing entitlements, coordination of services, and connecting with external somatic and mental health services. The program served 222 clients over the course of the grant.
Grantee Organization: Helping Up Mission
Focus Area: Dental
Grant and Amount: 20-005 ($95,000)
Grant Project Description: This program will support expansion of the current women's oral health program at Helping Up Mission which provides low-cost/free preventive and restorative dental services to homeless women in recovery from drug addiction. Women enrolled in the program reside at the Mission where they receive an array of social support and wraparound services, case management and vocational assistance.
Organization Contact Information: Helping Up Mission
Grantee Organization: Baltimore City Health Department
Focus Area: Women's Health
Grant and Amount: 20-009 ($350,000)
Grant Project Description: This program, Reproductive Planning and Access Now!, will expand access to reproductive planning for women engaged in SUD treatment and recovery services who experience a disproportionately high level of unmet reproductive health needs and have other complex health and social service needs. Through improved access to on-site clinical family planning services, the program seeks to reduce the number of unintended pregnancies, which are estimated to represent 90% of pregnancies among women with SUD.
Organization Contact Information: health.baltimorecity.gov
Grantee Organization: Tuerk House
Focus Area: Behavioral Health
Grant and Amount: 20-015 ($180,000)
Grant Project Description: This program will support the opening of an 'urgent' care center at the current Tuerk House location in Baltimore City. The new center will offer greater access to a range of behavioral health services including substance use and medication-assisted treatment. The program will also help connect clients to community resources from ongoing healthcare to housing assistance and workforce development opportunities which contribute to successful recovery. Grant funding will be used primarily to support the hiring of clinical professional and peer recover staff for the new center.
Organization Contact Information: Tuerk House
Grantee Organization: Baltimore City Health Department
Focus Area: Behavioral Health
Grant and Amount: 20-016 ($220,000)
Grant Project Description: This program will fund expansion of the current mobile health clinic program called Healthcare on the Spot (The Spot). The Spot currently offers integrated medical services and co-locates with substance use programs, drop-in centers and a syringe exchange program run by the Baltimore City Health Department. This proposal will help The Spot engage individuals that use drugs for expanded HCV testing and treatment.
Organization Contact Information: health.baltimorecity.gov
Grantee Organization: Behavioral Health Leadership Institute
Focus Area: Behavioral Health Leadership Institute
Grant and Amount: 20-017 ($220,000)
Grant Project Description: This program will expand the Behavioral Health Leadership Institute's 'pop up' clinic program that uses a mobile van to provide access to low-threshold medication for opioid use disorder to vulnerable residents at two new sites in Baltimore City that have requested these services. The target population includes justice-involved residents who are shunned from traditional SUD programs and homeless individuals impacted by multiple barriers to accessing health care services. The program currently provides services a half-day per week per site, at three sites in Baltimore City.
Organization Contact Information: Behavioral Health Leadership Institute
Grantee Organization: JHU - Rales Health Center
Focus Area: Diabetes/Food Security
Grant and Amount: 20-024 ($300,000)
Grant Project Description: Funding for this program by The Johns Hopkins University School of Medicine, Department of Pediatrics will be used to expand the SBHC program at the KIPP Harmony and KIPP Ujima Village Academies, serving K-8 low-income minority children at the Rales Health Center in West Baltimore. This program will increase access to healthy food for children living in Healthy Food Priority areas, facilitate early clinical identification of children who are overweight and obese, and engage these students in weight management clinical care. The program will screen for food security and develop a system for referral to the school-based food pantry and support ongoing implementation of the Fitness Gram screening program.
Organization Contact Information: JHU Rales Health Center
Grantee Organization: Associated Catholic Charities - My Brother's Keeper
Focus Area: Diabetes/Food Security
Grant and Amount: 20-026 ($220,000)
Grant Project Description: This program by My Brother's Keeper, in partnership with St. Agnes Ascension Health, will establish an on-site medical home for My Brother's Keeper clients and low-income, underserved and at-risk adults and teenage residents of the surrounding area. The new clinic will provide treatment for acute illness and chronic disease, including diabetes and its comorbidities. Services will be targeted to those who currently access primary and/or urgent care through emergency departments. Clinic patients will be screened for diabetes and prediabetes and have access to evidence-based lifestyle change programs, Diabetes Self-Management Education and Supports (DSMES), Medical Nutrition Therapy (MNT) and the National Diabetes Prevention Program.
Organization Contact Information: My Brother's Keeper
Grantee Organization: Baltimore City Fire Department
Focus Area: Primary Care
Grant and Amount: 19-004 ($600,000)
Grant Project Description: This project would expand the City's existing EMS/Mobile Integrated Health program by adding a new data analytics platform and Artificial Intelligence to identify and address low acuity calls so that the City EMS can be freed up to respond to more serious calls. The data analytics would also inform home visits performed by the community paramedicine team. The project also involves an interactive, two-way patient communication, monitoring patients for self-reported unmet needs and other risks for readmission and/or calling 911 again, thereby activating patients most at-risk for extended home visiting services.
Organization Contact Information https://fire.baltimorecity.gov/
Grantee Organization: Mosaic Community Services
Focus Area: Dental
Grant and Amount: 19-007 ($325,000)
Grant Project Description: This project would expand access to dental services for the organization’s highly vulnerable patients with mental illness and/or substance use disorders, many of whom are impacted by chronic diseases that include diabetes and hypertension, have poor diets, and have delayed seeking dental care. The project would provide dental services from private providers who would serve Mosaic clients in the Psychiatric Rehabilitation Program and Health Home Program in six sites in Baltimore City, Baltimore, Harford, and Carroll Counties.
Organization Contact Information: http://www.mosaicinc.org//
Grantee Organization: Chase Brexton Health Services
Focus Area: Dental
Grant and Amount: 19-009 ($300,000)
Grant Project Description: This project would support a Chase Brexton and Johns Hopkins Hospital community-hospital partnership to refer individuals seeking oral health care services at the hospital ED to dental care provided at Chase Brexton. The goals of the project are to provide a permanent dental home for patients at Chase and reduce avoidable dental-related ED visits. Under the project, Chase and Hopkins will develop a formalized referral process with the Hopkins ED for patients with urgent oral health needs. The project involves providing patient transportation; financial assistance for medications; enrollment for health insurance options; health education; care coordination and outreach for missed appointments; and referrals for medical and psychosocial support services (This grant is also listed in 'Reducing avoidable ED visits and promoting care in the community').
Organization Contact Information: https://www.chasebrexton.org/
Grantee Organization: Helping Up Mission
Focus Area: Behavioral Health
Grant and Amount: 19-013 ($385,000)
Grant Project Description: This project would provide an array of residential, support, vocational, and health care services for vulnerable women who are low-income, experiencing homelessness, and have substance use disorder. This project involves two new programs: (1) a 14-bed Joint Commission on Accreditation of Healthcare Organizations accredited transitional recovery housing program in partnership with Johns Hopkins Hospital Broadway Center for Addictions; and (2) a 16-bed long-term Spiritual Recovery Program that focuses on integrated modalities of care, focusing on hope, health, housing, and a sense of purpose and community. Both of these programs are modeled after success in serving adult males.
Organization Contact Information: https://helpingupmission.org/
Grantee Organization: Shepherd’s Clinic
Focus Area: Behavioral Health
Grant and Amount: 19-014 ($260,000)
Grant Project Description: This project would expand the clinical service offerings in its existing behavioral health program to include treatment for substance use disorder. The project would integrate a primary care opioid treatment program as part of the existing Behavioral Health Program, expanding services to include Medication-Assisted Therapy (MAT) for opioid use disorders, routine and special diagnostic procedures and toxicology tests, psychiatric/psychological assessments and treatment through the clinic’s Behavioral Health Program. The current Behavioral Health Program provides psychotherapy, psychiatry services, case management resources, and psychoeducation sessions.
Organization Contact Information: https://www.catholiccharities-md.org/
Grantee Organization: Associated Catholic Charities
Focus Area: Behavioral Health
Grant and Amount: 19-015 ($510,000)
Grant Project Description: This project would expand the clinical service offerings in its existing behavioral health program to include treatment for substance use disorder. The project would integrate a primary care opioid treatment program as part of the existing Behavioral Health Program, expanding services to include Medication-Assisted Therapy (MAT) for opioid use disorders, routine and special diagnostic procedures and toxicology tests, psychiatric/psychological assessments and treatment through the clinic’s Behavioral Health Program. The current Behavioral Health Program provides psychotherapy, psychiatry services, case management resources, and psychoeducation sessions.
Organization Contact Information: \ http://shepherdsclinic.org/
Grantee Organization: Baltimore Medical Systems, Inc.
Focus Area: Childhood Obesity
Grant and Amount: 19-020 ($200,000)
Grant Project Description: This project would provide enhanced childhood obesity and nutrition intervention in the Collington Square Elementary/Middle School School-based Health Center. The project offers counseling, health monitoring, and nutrition education as well as promoting physical activity and nutrition lessons during resource periods that also engages parents and guardians. The project also implements “CATCH Kids”; a program to provide motivation interviewing and obesity management training for BMS staff.
Organization Contact Information: https://bmsi.org/
Grantee Organization: Esperanza Center
Focus Area: Primary Care
Grant and Amount: 18-007 ($150,000)
Grant Project Description: This project would increase access to culturally competent, patient-centered care in a free clinic in Baltimore City, perhaps the only one in the state that serves only low-income uninsured individuals. The project would increase the number of hours of staffing for the clinic to provide primary care as well as referrals to specialty care and services to address social determinants of health. The program at the Esperanza Center offers the strong potential of reducing avoidable hospital utilization for primary care services by the target population.
Organization Contact Information: https://www.catholiccharities-md.org/services/esperanza-center/
Grantee Organization: Potomac Healthcare Foundation
Focus Area: Behavioral Health
Grant and Amount: 18-009 ($210,000)
Grant Project Description: This project would establish a 16-bed specialty recovery house in West Baltimore for underserved, low-income young adults with opioid addiction to provide a supervised, developmentally appropriate recovery environment with support for outpatient treatment. The project would provide an immediate linkage to care from the ED or hospitalization with a 'warm handoff' and rapid initiation of treatment, including residential recovery support and buprenorphine as needed. While at the center, patients would benefit from an on-campus community treatment facility which would provide a full spectrum of behavioral health treatment for opioid addiction and co-occurring disorders. The project would expand access to integrated services in Baltimore City, an area of the state that is particularly in need of these services.
Organization Contact Information: www.mountainmanor.org
Grantee Organization: Care For Your Health
Focus Area: Primary Care
Grant and Amount: 18-017 ($75,000)
Grant Project Description: his project would increase access to geriatric primary care services for home bound and low‐ income senior citizens, who do not have or have not been able to see a primary care provider. The program has three sites in NE Montgomery County, in Pine Ridge and in Baltimore City, and the CHRC grant would support the expansion of the program to a new site in Baltimore City and support home visitation to seniors unable to travel for care. The program would also encourage older adults who are at risk of hospitalization or death to develop advanced directives and an active care plan..
Organization Contact Information: http://careforyourhealth.org
Grantee Organization: Baltimore City Health Department
Focus Area: Infant Mortality
Grant and Amount: 18-018 ($250,000)
Grant Project Description: This project would support the continued implementation of the B’More for Healthy Babies (BHB) Initiative. Grant funds would be utilized to support the salaries of pregnancy engagement specialists at Health Care Access Maryland and Baltimore Healthy Start who will use aggressive, trauma‐informed strategies to outreach pregnant women who are currently unable to be located though traditional outreach methods. The investigators will direct vulnerable pregnant women and newborns into appropriate obstetric and pediatric homes.
Organization Contact Information: health.baltimorecity.gov
Grantee Organization: Baltimore City Health Department
Focus Area: Childhood Obesity
Grant and Amount: 17-012 ($150,000)
Grant Project Description: This two-year grant, expanding on an existing CHRC grant, will expand the “Baltimarket Healthy Stores” program, which works with retail stores to expand access to affordable, healthy food options that serve low-income children and families. Under the program, additional stores will be recruited to the Baltimarket program. The Baltimore City Health Department will provide technical assistance to these stores, focusing on the implementation of federal SNAP/food stamp changes, and employ young residents as community health educators.
Organization Contact Information: health.baltimorecity.gov
Grantee Organization: Helping Up Mission
Focus Area: Dental
Grant and Amount: 17-021 ($150,000)
Grant Project Description: This three-year grant is being used expand an existing program they have with the University of Maryland Dental School to help homeless residents secure comprehensive dental services. This program will build on Helping Up Mission's existing partnerships with Towson University, the Health Alliance, Johns Hopkins Hospital, UMSOD, and the DHMH Office of Oral Health. CHRC grant funding is being utilized for staff salaries and to provide subsidized dental services from outside providers.
Organization Contact Information: helpingupmission.org
Grantee Organization: The Family Tree
Focus Area: Infant Mortality
Grant and Amount: 17-017 ($150,000)
Grant Project Description: This two-year grant provides funding to implement an evidence-based, cost-effective, 'Maryland Family Connects' program, which is a home visitation program for at-risk mothers designed to support new mothers in caring for their newborns by providing a brief intervention strategy (3-7 visits post-partum).
Organization Contact Information: www.familytreemd.org
Grantee Organization: Behavioral Health Systems Baltimore
Focus Area: Behavioral Health
Grant and Amount: 16-006 ($600,000)
Grant Project Description: This three-year grant is being utilized to support the operating costs of a new “Stabilization Center” in Baltimore. The center will be located at the current site of a Federally Qualified Health Center and will intercept EMS calls for alcohol/substance use, divert these individuals from hospital emergency departments, and refer them to services at the Stabilization Center. Individuals receive case-management after discharge from the Center. Grant funds are being utilized to support the salaries of peer recovery support specialists.
Organization Contact Information: http://www.bhsbaltimore.org
Grantee Organization: Potomac Healthcare Foundation
Focus Area: Behavioral Health
Grant and Amount: 16-007 ($275,000)
Grant Project Description: This thee-year grant is utilizing funding to establish a 50-bed residential Recovery Support Center in West Baltimore. The project addresses three of the seven goals of the Governor’s Heroin and Opioid Emergency Task Force by: (1) expanding access to treatment by removing one of the barriers for accessing care, housing; (2) enhancing the quality of treatment via an evidence-based approach that utilizes residential recovery housing; and (3) boosting overdose prevention efforts, as “stable housing and quality treatment are the bulwarks against overdose.” Grant funds are being utilized to support the salary costs of case managers at the program.
Organization Contact Information: http://www.mountainmanor.org
Grantee Organization: Bon Secours Baltimore Health System
Focus Area: Behavioral Health
Grant and Amount: 16-008 ($125,000)
Grant Project Description: This three-year -grant supports the creation of a new Forensic Diversion Program (FDP) for inmate pre-trial mental health stabilization prior to competency determination from the courts. The goal of the Bon Secours FDP program is to enable court-involved individuals with serious mental illness awaiting trial to receive services at Bon Secours in lieu of another placement in the state hospital system. Grant funds are being utilized to support staff salaries and training.
Organization Contact Information: http://www.bonsecoursbaltimore.com
Grantee Organization: Shepherd’s Clinic
Focus Area: Primary Care
Grant and Amount: 16-010 ($105,000)
Grant Project Description: This two-year grant is being used to support a diabetes Self-management program at a free clinic in Baltimore City that predominantly serves low-income, un/underinsured individuals by providing a number of services including primary, specialty, and wellness programs. The proposal requests funding to triple the capacity of the Diabetes Self-Management Program and grant funds are being utilized to hire a part-time certified diabetes educator.
Organization Contact Information: www.shepherdsclinic.org
Grantee Organization: Baltimore City Health Department
Focus Area: Infant Mortality
Grant and Amount: 16-015 ($250,000)
Grant Project Description: This two-year grant provides funding to support the continued implementation of the B’More for Healthy Babies (BHB) Initiative. Grant funds are being utilized to support the salaries of two new public health investigators who will use aggressive, trauma-informed strategies to outreach pregnant women who are currently unable to be located though traditional outreach methods or who refuse to talk to care coordinators. The investigators use cutting-edge strategies to direct vulnerable pregnant women and newborns into appropriate obstetric and pediatric homes.
Organization Contact Information: health.baltimorecity.gov
Grantee Organization: Total Health Care, Inc.
Focus Area: Dental
Grant and Amount: 15-004 ($180,000)
Grant Project Description: This three-year grant involves a new collaboration between Total Health Care and Mercy Hospital to ensure all pregnant women patients of Total who are seen by Mercy OB providers will receive the benefit of integrated OB and dental care. The Total dental proposal offers an innovative hospital-community partnership with Mercy and could serve as a model for other areas of the state. Grant funding is being utilized to provide 'seed money' to hire a dentist who will provide oral health education sessions during 6-week pregnancy group sessions.
Organization Contact Information: www.totalhealthcare.org
Grantee Organization: Medstar Union Memorial Hospital
Focus Area: Primary Care
Grant and Amount: 15-009 ($150,000)
Grant Project Description: This two-year grant supports a hospital-community partnership to reduce preventable hospital ED visits and refer individuals to ongoing primary care services in community based settings. The grant involved hospital-community partnerships and funded a patient navigator position who worked with 2,695 individuals over the course of the program to link individuals with a primary care provider.
Organization Contact Information: http://www.medstarunionmemorial.org/
Grantee Organization: Catholic Charities - Esperanza Center
Focus Area: Primary Care
Grant and Amount: 15-010 ($200,000)
Grant Project Description: This two-year grant award is being used to support a program to expand clinic hours at the Esperanza Center from 17 to 28 per week. The center serves low-income un/underinsured patients in Baltimore City and is supported by Catholic Charities and Johns Hopkins School of Medicine. Grant funding utilized covers the salary costs program personnel.
Organization Contact Information: http://www.catholiccharities-md.org/immigrants/
Grantee Organization: Planned Parenthood-Maryland
Focus Area: Infant Mortality
Grant and Amount: 14-003 ($225,000)
Grant Project Description: This two-year grant supports a program which seeks to reduce infant mortality rates by increasing access to comprehensive women’s health services in Baltimore, Anne Arundel, and Wicomico Counties. Grant funds are being utilized to provide same-day access to Long Acting Reversible Contraception (LARC), as well as to prevent substance-exposed pregnancies by implementing use of the Screening, Brief Intervention, and Referral to Treatment (SBIRT) tool. The grantee is also providing outreach to clients to educate them about the importance of health insurance and connect eligible individuals to coverage.
Organization Contact Information: www.plannedparenthood.org/planned-parenthood-maryland
Grantee Organization: Health Care for the Homeless
Grants and Amounts: 14-009 ($140,000)
Focus Area(s): Primary Care
Grant Project Description: This one-year grant supported a program that provided a medical home for homeless individuals in Baltimore City who were high utilizers of the City’s emergency departments. The program provided health-related services, education, and advocacy to reduce the incidence and burdens of homelessness. Over the duration of the program 66 individuals received care through 1,040 encounters.
Organization Contact Information: www.hchmd.org
Grantee Organization: Health Care Access Maryland
Focus Area: Primary Care
Grants and Amount: 14-011 ($800,000)
Grant Project Description: This three-year grant supports a program that targets individuals with chronic disease conditions who frequently utilize the Sinai Hospital emergency departments and promotes access to primary and preventative care services in the community. The program helps residents enroll in public health care coverage and navigate the complex health care system. Grant funds are being used to support new ED diversion teams deployed in two hospitals in Baltimore City (Sinai and Northwest Hospitals).
Organization Contact Information: www.healthcareaccessmaryland.org
Grantee Organization: Mosaic Community Services
Focus Area: Behavioral Health
Grant and Amount: 14-013 ($550,000)
Grant Project Description: This two-year grant supported a collaborative program between Mosaic and Baltimore Medical System to provide integrated behavioral health and primary care services to residents of Baltimore City. Grant funds were utilized to support the Opening of the Sharfstein Center on N. Charles Street. Services provided included somatic, case management, addiction and behavioral health programs. Grant funds supported staff salaries.
Organization Contact Information: www.mosaicinc.org
Grantee Organization: Department of Pediatrics, University of Maryland
Focus Area: Childhood Obesity
Grant and Amount: 14-018 ($510,000)
Grant Project Description: This three-year grant supports the Heathiest Maryland Schools program which seeks to bring together pediatricians, schools, and communities to address childhood obesity, and to support interventions in three Title I elementary schools in West Baltimore. Grant funding is utilized for staffing a program manager, a clinical coordinator, and a research assistant, as well as for data collection and analysis.
Organization Contact Information: http://medschool.umaryland.edu/pediatrics/
Grantee Organization: Baltimore City Health Department
Focus Area: Childhood Obesity
Grant and Amount: 14-019 ($750,000)
Grant Project Description: This three-year grant is being utilized to support the “Baltimarket Healthy Stores” program, which aims to prevent childhood obesity through a multi-level, community-based program that transforms the retail food environment. The program has three core elements: corner store, Youth Neighborhood Food Advocate, and grocery store-based nutrition education, and focuses on the following zip codes in West Baltimore: 21216, 21217, 21223, and 21229.
Organization Contact Information: http://baltimorehealth.org/>
Grantee Organization: Behavioral Health Leadership Institute
Focus Area: Behavioral Health
Grant Amount: 14-021 ($20,570)
Grant Project Description: This one-year grant allowed Behavioral Health Leadership Institute to develop a sustainability plan for the Partners in Integrated Treatment and Community Health (PITCH). The PITCH model provided for integration of a clinical team with trained community health workers and strong community partnerships. Grant funds were utilized to hire an expert to consult on financial sustainability and Medicaid reimbursement. Grant funds were leveraged by BHLI to receive additional funds from Jacob and Hilda Blaustein Foundation and the Zanvyl and Isabelle Krieger Fund and helped support the development of a Community Health Worker Toolkit.
Organization Contact Information: http://www.bhli.org/index.shtml
Grantee Organization: Baltimore City Health Department
Focus Area: Dental
Grant and Amount: 12-003 ($58,428)
Grant Project Description: The two-year grant supported a partnership between the Oral Health Services Program and the Immunization Program in the BCHD to ensure at-risk children and families receive preventative oral health education and dental care at an early juncture in the child's development. The program enrolled 1,102 patients over the duration of the grant.
Organization Contact Information: http://baltimorehealth.org/
Grantee Organization: Catholic Charities-Esperanza Center
Focus Area: Primary Care
Grants and Amount: 12-009 ($219,400)
Grant Project Description: This two-year grant enabled Catholic Charities to expand the successful Asociación Comunidad Saludable (ACS) Project which increased access to care for the uninsured Latino population in Baltimore City. Grant funds were used to hire a full-time nurse practitioner who provided primary care visits to children and adults. The grantee reported serving 3,156 patients through 6,498 visits over the duration of the grant.
Organization Contact Information: www.catholiccharities-md.org/immigrants/
Grantee Organization: Shepherd's Clinic
Focus Area: Primary Care
Grants and Amount: 12-010 ($160,000)
Grant Project Description: This two-year grant increased the capacity of the Shepherd’s Clinic to provide primary care services to low-income and uninsured residents of Baltimore City. The grant enabled Shepherd's Clinic to expand its hours of operations, reduce the current month-long wait time for an appointment by 50%, and address the clinic's rapid patient growth. The grantee reported serving 2,869 patients through 16,443 visits over the duration of the grant.
Organization Contact Information: http://shepherdsclinic.org/
Grantee Organization: Mosaic Community Services
Focus Area: Behavioral Health
Grant and Amount: 11-010 $200,000
Grant Project Description: This two-year grant supported a pilot program that integrated primary care services for individuals with a co-occurring mental health and substance abuse disorders. Participants were assessed for somatic health care needs, and connected with a primary care provider. Grant funding was utilized for staff salaries. The grantee reported providing services to 316 individuals over the duration of the grant.
Organization Contact Information: http://www.mosaicinc.org/
Grantee Organization: People Encouraging People
Focus Area: Behavioral Health
Grant and Amount: 11-011 ($250,000)
Grant Project Description: This three-year grant supported the integration of a primary care program with existing behavioral, rehabilitative and support services. The program inserted primary care professionals within existing Assertive Community Treatment teams to provide added needed services to those with complex health and social needs. Grant funding was utilized for clinical staff salaries. This grantee reported serving 368 new individuals through 1,400 visits over the duration of the grant.
Organization Contact Information: http://www.peponline.org/aboutpep/
Grantee Organization: Baltimore Medical System, Inc. (BMS)
Focus Area: Infant Mortality
Grant and Amount: 10-003 ($300,000)
Grant Project Description: This three-year grant supported a program to improve access to prenatal care, improve birth outcomes, and provide a medical home to women and their children. The program was operated at BMS's Highlandtown Community Health Center and BMS at St. Agnes where the greatest number of BMS's prenatal patients receive their care. The program provided personalized care to women throughout their pregnancy and through one-year post-partum. The grantee reported serving 1,751 women through 2,423 over the duration of the grant.
Organization Contact Information: www.bmsi.org
Grantee Organization: Baltimore City Health Department
Focus Area: Primary Care
Grant and Amount: 09-002 ($160,000)
Grant Project Description: This two-year grant supported the Health Department's efforts to develop and implement a technical assistance and training project so school-based health centers (SBHC) bill public and private payors for health care services. The grant supported the health department’s efforts to provide training materials and technical assistance services aimed at assisting SBHCs develop and manage billing and collections systems.
Organization Contact Information: www.baltimorehealth.org
Grantee Organization: Coppin State University/Helene Fuld School of Nursing
Focus Area: Primary Care
Grant and Amount: 09-004 ($201,963)
Grant Project Description: This two-year grant supported the expansion of a school based health center program to serve the residents of Baltimore City. Funding was utilized to upgrade equipment, install health information technology to improve the health center's clinical records, and assist in billing and reimbursement from third party payers. The grantee reported providing services for 2,319 students over the duration of the grant.
Organization Contact Information: www.coppin.edu/nursing
Grantee Organization: Baltimore City Health Department - Substance Abuse Systems, Inc.
Focus Area: Behavioral Health
Grant and Amount: 09-010 ($250,000)
Grant Project Description: This two-year grant supported a program aimed at providing integrated, community-based treatment services using Integrated Dual Disorders Treatment (IDDT) for those with co-occurring disorders and criminal justice system involvement. Patient services were provided by a team of behavioral health, social service and criminal justice professionals. Grant funds were utilized to provide operational costs for the program. The grantee reported serving 48 individuals through 2,385 visits over the duration of the grant.
Organization Contact Information: http://health.baltimorecity.gov/
Grantee Organization: Baltimore City Health Department
Focus Area: Dental
Grant and Amount: 08-002 ($70,750)
Grant Project Description: This two-year grant supported the enhancement of dental services at the BCHD Dental Clinic by hiring a Public Health Dental Hygienist, providing additional Spanish language training for a dental assistant and incorporating a language translation services.
Organization Contact Information: http://baltimorehealth.org/
Grantee Organization: Baltimore Medical System
Focus Area: Primary Care
Grant and Amount: 08-009 ($293,930)
Grant Project Description: This two-year grant supported a program which expanded the current Electronic Health Record system at BMS to four additional health center locations, four school based health centers, and permitted connectivity to partner organizations such as laboratories, hospitals, and pharmacies. Grant funds were used to purchase computer software and equipment necessary for this upgrade.
Organization Contact Information: www.bmsi.org
Grantee Organization: Family Health Centers of Baltimore
Focus Area: Dental
Grant and Amount: 08-018 ($300,000)
Grant Project Description: The three-year grant supported a pediatric dental program that provided screenings and oral health educations in area schools and Head Start Locations and linked students to a dental home at FHCB. Under this grant, FHCB was able expand the dental clinic to include more days and evening hours and added a part-time pediatric dentists to allow FHCB to serve more children.
Organization Contact Information: http://fhcb.org/
Grantee Organization: Kernan Orthopedics and Rehabilitation
Focus Area: Dental
Grant and Amount: 08-019 ($287,410)
Grant Project Description: The two-year supported the Kernan Dental Service which is a teaching clinic for the University of Maryland’s Dental School. Grant funding enabled Kernan Dental Service to upgrade and replace worn and over-utilized equipment such as x-ray units and mobile dental carts and increase its capacity by adding personnel, an additional dental chair and equipping the operating room.
Organization Contact Information: www.kernan.org/dental/index.htm
Grantee Organization: Total Health Care
Focus Area: Primary Care
Grant and Amount: 08-022 ($100,250)
Grant Project Description: This one-year grant supported a program with Total Health Care to reduce ED visits for non-emergency conditions by clients accessing Maryland General Hospital's ED. The grantee placed Outreach Coordinators in the hospital's ED during peak usage hours to educate patients on appropriate ED use and to assist patients in connecting with a primary care provider in the community. The grantee reported an 8% reduction in ED visits at Maryland General Hospital from the year prior to the grant's implementation.
Organization Contact Information: www.totalhealthcare.org
Grantee Organization: University of Maryland Department of Family Medicine
Focus Area: Primary Care
Grant and Amount: 08-023 ($499,749)
Grant Project Description: This three-year grant supported the Better Access to Care (BAC) Program aimed at reducing hospital ED visits using the Chronic Care Model for patients with diabetes, depression and asthma. Patients were referred from the UM hospital ED and other community organizations. Grant funds were used to support the salary costs of program staff.
Organization Contact Information: www.medschool.umaryland.edu/familymedicine
Grantee Organization: Baltimore Medical System, Inc. (BMS)
Focus Area: Primary Care
Grant and Amount: 07-003 ($502,500)
Grant Project Description: This three-year grant supported the provision of culturally and linguistically appropriate health services to low-income Hispanic patients by improving medical interpretation services. BMS expanded access to primary care, pre and postnatal care, and specialty and diagnostic services for non-English speaking patients by providing on-site medical interpretation and case management. The grantee reported serving 6,320 patients through 42,000 patient visits over the duration of the grant.
Organization Contact Information: www.bmsi.org
Grantee Organization: Johns Hopkins Bayview
Focus Area: Behavioral Health
Grant and Amount: 07-008 ($485,479)
Grant Project Description: The three-year grant provided comprehensive primary care services to people living with serious mental illness. Services included preventative medicine, health education, health coaching and counseling. Initial outcomes provided by the grantee indicated that patients who received intensive services from the program compared to those who were referred to their primary care provider experienced a reduction in smoking (33.8%), visits to the emergency room (34.8%), and high cholesterol (44%). Grant funds were utilized to support staff salaries and supplies. The grantee reported that 268 individuals were served through 1,666 visits over the duration of the grant.
Organization Contact Information: www.hopkinsbayview.org/psychiatry
Grantee Organization: Union Memorial Hospital
Focus Area: Behavioral Health
Grant and Amount: 07-011 ($333,721)
Grant Project Description: This three-year grant funded the Buprenorphine Initiative program and an effective inpatient-to-outpatient transition program for Heroin and opiate addicted patients. After release from Union Memorial Hospital, patients were followed in the Adult Medicine Clinic (AMC) for buprenorphine (Suboxone) maintenance therapy according to a standard buprenorphine treatment protocol. Grant funds were utilized to support staff salaries and data collection. The grantee reported serving 902 individuals through 9,061 patient visits over the duration of the grant.
Organization Contact Information: http://www.medstarunionmemorial.org/