Grantee Organization: TidalHealth
Jurisdiction Served: Wicomico County
Grant and Amount: 23-18 ($700,000)
The program will address cultural and linguistic barriers for the Haitian community of Wicomico County to access maternal health care. TidalHealth will provide education and support before and during pregnancy, and after childbirth. Additionally, TidalHealth will establish collaborative partnerships among Haitian-Creole health care providers, community health workers, and health educators, and will create a new "workforce pipeline" for certified medical interpreters.
Grantee Organization: University of Maryland Upper Chesapeake Health
Jurisdiction Served: Harford County
Grant and Amount: 23-04 ($340,000)
The program will address higher rates of uncontrolled diabetes and avoidable emergency department (ED) utilization and hospitalizations for African American residents of Harford County by : (1) providing case management and linkages to community supports to individuals who visit the hospital emergency department for avoidable diabetes related complications as well as to other individuals referred by their PCPs; (2) offering culturally competent diabetes self-management education and diabetes prevention education; and (3) increasing peer support for individuals with diabetes and their families including through a virtual diabetes support group and a Spanish language support group.
Grantee Organization: Queen Anne's County Health Department
Jurisdiction Served: Queen Anne's County
Grant and Amount: 22-04 ($200,000)
This program will expand Mobile Integrated Community Health (MICH) services and leverage mobile technology to enhance access to a broad range of services for minority and low-income residents living with at least one chronic disease and multiple underlying medical conditions, and who face barriers to accessing care which have been exacerbated by the COVID-19 pandemic. The project will expand MICH capacity by funding the use of the “mHealth" app with wearable devices that allow mobile telehealth and provide access to weight/diet/fitness tracking and management, dosing reminders via text messaging and/or electronic devices, and access to nutritional consulting. Staff also will bring Diabetes Self-Management and the National Diabetes Prevention Programs directly to participants.
Grantee Organization: Calvert County Health Department
Jurisdiction Served: Calvert County
Grant and Amount: 22-03 ($480,000)
The “Highways to Health" program will target three communities at high risk for chronic diseases which have large minority populations and overall high socioeconomic needs. The project will initiate a mobile outreach and health van (MOV) to bring health screenings, health resources, and community linkages directly to vulnerable, hard-to-reach residents. The MOV will offer referrals to Primary Care Providers and to community partners for healthy lifestyle programs (Diabetes Prevention Program, Diabetes Self-Management Program, Tobacco Cessation) and physical activity programs. Nutrition counseling also will be provided.
Grantee Organization: Shepherd's Clinic
Jurisdiction Served: Baltimore City
Grant and Amount: 22-02 ($460,000)
The EMPOWER project aims 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 will be provided, and patients will be offered wellness services such as yoga/meditation classes, nutrition counseling, cooking demonstrations, and gardening tips. The project will address Social Determinant of Health (SDOH) needs including food security, transportation, health literacy education, and language services.
Grantee Organization: University of Maryland School of Nursing
Jurisdiction Served: Baltimore City
Grant and Amount: PW-22-09 ($2,400,000)
This project will address disparities in hypertension, mental health, and social isolation in West Baltimore (zip codes 21201, 21217, 21223, and 21229). 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: Johns Hopkins School of Medicine
Jurisdiction Served: Prince George's County
Grant and Amount: PW-22-04 ($2,000,000)
This project will address disparities associated with the high prevalence of sickle cell disease (SCD) and lack of access to a local comprehensive sickle cell project in Prince George's County, with specific focus on Upper Marlboro, Laurel and Capital Heights (zip codes 20773, 20707, and 20743). This project aims to reduce the number of adults who present to UMCP hospital for acute pain requiring hospital admission, and to improve access to SCD modifying treatment and transition services for adolescents and young adults to reduce hospitalizations. This comprehensive sickle cell project includes a new infusion clinic at UM Capital Region Medical Center. CHWs will identify participants who lack resources to facilitate access, coordinate their care, and provide SCD education. A nurse navigator will facilitate interventions to address SDOH needs, and a nutritionist will develop a food plan for each participant.
Grantee Organization: Baltimore City Fire Department
Jurisdiction Served: Baltimore City
Grant and Amount: 19-004 ($600,000)
Grant Project Description: This two-year 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 (This grant is also listed in 'Expanding access to primary care services).
Organization Contact Information: https://fire.baltimorecity.gov/
Grantee Organization: Chase Brexton Health Services
Jurisdiction Served: Baltimore City
Grant and Amount: 19-009 ($300,000)
Grant Project Description: This two-year project supports community-hospital partnership between Chase Brexton and Johns Hopkins Hospital 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 'Expanding access to dental services').
Organization Contact Information: https://www.chasebrexton.org/
Grantee Organization: Esperanza Center.
Jurisdiction Served: Baltimore City
Grant Amount: 18-007 ($150,000)
Grant Project Description: This two-year project increases 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 (This grant is also listed in 'Expanding access to primary care services').
Organization Contact Information: www.catholiccharities-md.org/services/esperanza-center/health-center
Grantee Organization: Wicomico County Health Department/EMS
Jurisdiction Served: Wicomico County
Grant and Amount: 18-006 ($90,000)
Grant Project Description: This two-year project aims to reduce preventable 911 calls through the use of a team consisting of an emergency medical technician and a registered nurse. The team would identify frequent callers to 911 for non-emergent conditions and would conduct welfare checks, case management, safety planning, and refer patients to primary care physicians, medical specialists, and, if necessary, in-home care providers. The program offers the potential to help reduce avoidable EMS and hospital utilization services and is replicable in other rural areas of the state (This grant is also listed in 'Expanding access to primary care services').
Organization Contact Information: www.wicomicohealth.org
Grantee Organization: Prince George’s County Fire/EMS
Jurisdiction Served: Prince George’s
Grant and Amount: 18-005 ($175,000)
Grant Project Description: This two-year grant supports a Mobile Integrated Health project which aims to reduce preventable 911 calls through the use of community paramedics who would interact with at-risk residents who frequently call 911 for non-emergent conditions. The integrated health team would connect these residents with quality healthcare services and other necessary community supports. The program offers the 2 potential to help reduce avoidable EMS and hospital utilization services and is replicable in other areas of the state (This grant is also listed in 'Expanding access to primary care services').
Organization Contact Information: http://www.princegeorgescountymd.gov/222/FireEmergency-Medical-Services
Grantee Organization: Anne Arundel Health Department
Jurisdiction Served: Anne Arundel
Grants and Amount: 17-014 ($200,000)
Grant Project Description: This two-year grant is being used to expand access to emergency dental services for low-income adults in Anne Arundel County, with a particular emphasis on diverting preventable dental-related ED visits. The target population is low-income Medicare and Medicaid adults. The project will build on the existing REACH Program in Anne Arundel by linking patients with private dentists and building the capacity of the existing dental clinic(s) at the Health Department to serve more residents. CHRC grant funding is being utilized to support the salary of a dental patient navigator and to provide discounted costs for dental services to program participants (This grant is also listed in 'Expanding access to dental services').
Organization Contact Information: http://www.aahealth.org/
Grantee Organization: Lower Shore Clinic
Jurisdiction Served: Lower Shore
Grant and Amount: 16-012 ($105,000)
Grant Project Description: This two-year grant provides funding to support the 'CareLink' program that targets individuals with behavioral health needs who Present at the Peninsula Regional Medical Center (PRMC) ED in high volumes and provides intensive case management services for these individuals in a community setting post-hospital discharge. The proposal involves a partnership with PRMC and is designed to help reduce 30-day readmission rates for individuals participating in the program. CHRC grant funds are being utilized to support the salary costs of program staff (This grant is also listed in 'Increasing Access to Integrated Behavioral Health Services').
Organization Contact Information: http://www.gogettersinc.org/Lower-Shore-Clinic.html
Grantee Organization: Charles County Health Department
Jurisdiction Served: Charles
Grant and Amount: 16-013 ($400,000)
Grant Project Description: This three-year grant supports an innovative “public health-EMS-hospital” partnership that seeks to address utilization of EMS and ED services in Charles County by assisting frequent ED/EMS users to manage their chronic conditions in a primary care setting or at home. The program is a collaboration among the Charles County Health Department, Charles EMS, and Charles Regional Hospital. Grant funding is being utilized to support a Mobile Integrated Healthcare team comprised of a paramedic, a nurse practitioner, and two community health workers (This grant is also listed in 'Expanding Access to Primary Care Services').
Organization Contact Information: www.charlescountyhealth.org
Grantee Organization: Family Services, Inc.
Jurisdiction Served: Montgomery County
Grant Amount: 15-006 ($250,000)
Grant Project Description: This two-year grant provides funding to expand Family Services' CareLink program to Holy Cross Hospital and Holy Cross Germantown Hospital. The CareLink program was previously successfully implemented at Washington Adventist Hospital and Shady Grove Hospital. The program targets individuals at a high risk for readmission who have behavioral health needs and/or medical conditions complicated by socio-economic factors. Grant funding is utilized to support the salary costs program staff (This grant is also listed in 'Increasing Access to Integrated Behavioral Health Services').
Organization Contact Information: http://www.fs-inc.org/
Grantee Organization: Harford County Health Department
Jurisdiction Served: Harford County
Grant and Amount: 15-008 ($320,000)
Grant Project Description: This three-year grant provides funding to support the partnership between Harford Health Department and Upper Chesapeake Health (UCH) to identify high-risk, high-cost populations and would 'integrate' the care coordination efforts of Harford Health Department with disease management efforts of UCH. Grant funds are utilized to cover the salary costs of program staff (This grant is also listed in 'Expanding Access to Primary Care Services').
Organization Contact Information: http://harfordcountyhealth.com/
Grantee Organization: Medstar Union Memorial Hospital
Jurisdiction Served: Baltimore City
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. (This grant is also listed in 'Expanding Access to Primary Care Services').
Organization Contact Information: http://www.medstarunionmemorial.org/
Grantee Organization: Health Care Access Maryland
Jurisdiction Served: Baltimore City
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) (This grant is also listed in 'Expanding Access to Primary Care Services').
Organization Contact Information: www.healthcareaccessmaryland.org
Grantee Organization: Total Health Care
Jurisdiction Served: Baltimore City
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 (This grant is also listed in 'Expanding Access to Primary Care Services').
Organization Contact Information: www.totalhealthcare.org
Grantee Organization: University of Maryland Department of Family Medicine
Jurisdiction Served: Baltimore City
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 (This grant is also listed in 'Expanding Access to Primary Care Services').
Organization Contact Information: www.medschool.umaryland.edu/familymedicine
Grantee Organization: Upper Chesapeake Health
Grant and Amount: 08-024 ($485,743)
Jurisdiction Served: Harford County
Grant Project Description: This three-year grant supported the development of a comprehensive ED diversion program to redirect uninsured patients away from using emergency rooms for non-emergent visits by redirecting uninsured and underinsured patients towards a medical home for primary and preventative care, as well as linking them to a comprehensive community based continuum of care (mental health, specialty care, substance abuse, entitlement programs, etc.). The program provided a medical home for patients at the Upper Chesapeake HealthLink Primary Care Clinic. Grant funding was utilized to support staff salaries. During the three year grant period, 2,487 patients were served by the HealthLink PCC (This grant is also listed in 'Expanding Access to Primary Care Services').
Organization Contact Information: http://www.uchs.org/
Grantee Organization: Chase Brexton Health Services Inc.
Grant and Amount: 07-005 ($200,000)
Jurisdiction Served: Howard County
Grant Project Description: This two-year grant supported a program aimed at reducing avoidable visits to the emergency department at Howard County General Hospital. The program employed outreach workers in the ED to connect patients to a Chase Brexton health center location for follow-up care. Funds were used to support personnel costs and to implement a digital interface between the hospital and Chase Brexton. The program served over 600 patients and provided for over 900 patient visits in ambulatory care settings (This grant is also listed in 'Expanding Access to Primary Care Services').
Organization Contact Information: www.chasebrexton.org
Grantee Organization: Frederick Community Action Agency
Jurisdiction Served: Frederick County
Grant Amount: 07-006 ($353,585)
Grant Project Description: This three-year grant supported the Access to Care Program which provided primary health care services to low-income, uninsured adults and children in Frederick County. CHRC grant funds were utilized to support salary costs for staff to implement this program. This grant allowed for 1,324 patients to be served and provided these patients with 3,740 visits in ambulatory care settings (This grant is also listed in 'Expanding Access to Primary Care Services').
Organization Contact Information: www.cityoffrederick.com/Index.aspx?NID=183
