Grantee Organization: Wicomico County Health Department/EMS
Jurisdiction Served: Wicomico County 
Focus Area: Primary Care
Grant and Amount: 20-001 ($270,000) 
Grant Project Description: This program will support expansion of the current Mobile Integrated Health/EMS diversion program in Salisbury, providing real time access to primary and preventative care services, and chronic disease management in people's homes. This project seeks to serve Wicomico County residents outside the Salisbury City Fire District service area. The current CHRC grant funded MIH program is one of several grants recently highlighted in the CHRC's Maryland's Rural Health Stories project.

Organization Contact Information: www.wicomicohealth.org​

Grantee Organization: Frederick Health Hospital 
Jurisdiction Served: Frederick County 
Focus Area: Primary Care
Grant and Amount: 20-002 ($175,000) 
Grant Project Description: This program will support and expand a care coordination service program for low-income seniors living in single-unit housing who typically present with complex health and social service needs. The program will provide an array of services and care coordination that will enable these residents to continue living at home and avoid hospital utilization. The program will be jointly implemented by the Frederick Health System and Frederick County Aging Department. Implementation of this project could provide a worthwhile blueprint for other jurisdictions looking to prepare for its aging population. 
Organization Contact Information: Frederick Health Hospital​​​​

Grantee Organization: Mobile Medical Care
Jurisdiction Served: Montgomery County 
Focus Area: Primary Care
Grant Amount: 20-003 ($140,000) 
Grant Project Description: The program will expand access to health care services by increasing clinical capacity at the existing East Montgomery Service Center from 2.5 days to 3.5 days per week and increase access to behavioral health services from one to two days per week. The expanded capacity will provide comprehensive healthcare services to low-income uninsured individuals and Medicaid and Medicare enrollees. Expansion of the bilingual integrated behavioral health services that MobileMed currently provides is a collaboration with Aspire Counseling.
Organization Contact Information: Mobile Medical Care

Grantee Organization: Vietnamese American Services
Jurisdiction Served: Montgomery County 
Focus Area: Primary Care
Grant Amount: 20-004 ($75,000) 
Grant Project Description: Vietnamese American Services focuses on serving low-income clients with limited English proficiency. Vietnamese residents surveyed by Vietnamese American Services report that they face language barriers in accessing care. Only two local primary care physicians speak Vietnamese and these providers are not accepting new Medicaid patients. The program will assist Vietnamese senior residents to register for health insurance and gain access to healthcare. A CHW position funded under the grant will help facilitate referrals to the MobileMed clinic and help connect these seniors to existing resources. Funding could lead to the establishment of the first senior day care center serving Vietnamese residents in Montgomery County.
Organization Contact Information: Vietnamese American Services

Grantee Organization: Helping Up Mission
Jurisdiction Served: Baltimore City
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: Prince George's County Health Department
Jurisdiction Served: Prince George's County 
Focus Area: Women's Health
Grant and Amount: 20-006 ($300,000) 
Grant Project Description: This program will support a care management program to improve reproductive and maternal health as well as expand care management to improve health outcomes for high-risk racial/ethnic minority females who are pre-conceptual, pregnant, or post-partum. The target population is women referred to the Department's Administrative Care Coordination Unit (ACCU), which has a caseload of 1,250 women. The proposal states that the program will bill third-party payers for care coordination services. The proposal states that the program will emphasize addressing social determinants of health.
Organization Contact Information: Prince George's County Health Department

Grantee Organization: Access to Wholistic & Productive Living Institute
Jurisdiction Served: Prince George's County 
Focus Area: Women's Health
Grant and Amount: 20-007 ($335,000) 
Grant Project Description: This program will fund the Bright Beginnings of Prince George's County project to assist high-risk, racial/ethnic minority women who are pregnant, postpartum or diagnosed with cardiovascular disease and/or Type 2 diabetes access to needed health and social services in a timely and effective manner. CHWs will be assigned to provide care coordination, patient navigation, and health education services to assist women to overcome social determinants of health and adopt preventive behaviors to achieve better health outcomes. A lifestyle coach will support healthy eating and active living measures.
Organization Contact Information: Access to Wholistic & Productive Living Institute​

Grantee Organization: Somerset County Health Department
Grant and Amount: 20-008 ($300,000) 
Jurisdiction Served: Wicomico County 
Focus Area: Primary Care
Grant Project Description: This program will support the opening of a new school-based wellness center (SBWC) at Washington High School for students and staff. Many students who attend Washington High School live in distressed neighborhoods and are at greater risk for negative health outcomes including poor physical and mental health, delinquency, and high-risk sexual behavior. The SBWC will address several healthcare service delivery gaps, social determinants of health and health disparities. The CHRC has a long history of supporting SBHCs (a designated community health resource) and currently staffs the Council on Advancement of School-Based Health Centers.
Organization Contact Information: http://somersethealth.org/​

​

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: Corsica River Mental Health Services
Grant and Amount: 20-010 ($215,000)
Focus Area: Primary Services 
Grant Project Description: The Care Connections program will support a care transition team to provide services to individuals following hospital discharge. The Care Connections Team will conduct comprehensive health assessments and develop a person-centered care plan within 2 to 3 days of hospital discharge.  The Team will use Motivational Interviewing, Illness Management Recovery, a Wellness Recovery Action Plan and Family Psychoeducation practices to initiate and maintain participant engagement. The program plans to use the GoMo Health Concierge mobile application to encourage participants to take a proactive approach to managing their care, and deliver personalized text messages about nutrition, health, exercise and emotional support. The program will also support individuals from Caroline, Dorchester, Kent and Talbot counties.  

Organization Contact Information: Corsica River Mental Health Services​​​

Grantee ​Grantee Organization: Family Healthcare of Hagerstown, formerly Walnut Street Health Center.
Jurisdiction Served: Washington County 
Grant and Amount: 19-002 ($225,000) 
Grant Project Description: This project would provide health care and care management services for complex patients who are chronically ill and/or discharged from the hospital.  The project would employ two LPNs to provide telephone and face-to-face support for individuals before their first provider visit to address barriers of care to the applicant upon referral, to perform lengthy medication reconciliations, and to obtain medical histories.  The project would decrease patient no-show rates, thereby generating additional patient fee-for-service revenue. 
Organization Contact Information: https://familyhch.org/

 Grantee Organization: Lower Shore Clinic.​
Jurisdiction Served: Mid-shore 
Grant and Amount: 19-003 ($150,000) 
Grant Project Description: This project would expand the Lower Shore Clinic’s existing Assertive Community Team (ACT) into Caroline, Dorchester, and Talbot Counties.  Clients served by ACT teams are individuals with serious and persistent mental illness and often have complex comorbid medical health conditions and are utilizers of high-cost services.  The ACT team, once fully staffed, would consist of a Psychiatric Nurse Practitioner, an RN, a Substance Use Counselor, and a Vocational Counselor.  An ACT team would provide behavioral health services for individuals with substance use treatment needs, assist clients in developing preventative health care skills and relationships with primary care providers, and address social determinants of health. 
Organization Contact Information: https://www.lowershoreclinic.org/

Grantee Organization: Baltimore City Fire Department
Jurisdiction Served: Baltimore City 
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 (This grant is also listed in 'Reducing avoidable ED visits and promoting care in the community​'). 

Organization Contact Information: https://fire.baltimorecity.gov/

Grantee Organization: Health Partners
Jurisdiction Served: Charles County
Grant and Amount: 19-005 ($260,000) 
Grant Project Description: This project would implement a new care management program at Health Partners to increase patient participation in disease management, increase preventative screenings, and reduce avoidable hospital ED visits.  The applicant has provided services to underserved residents in Charles County for more than 25 years, and this project would expand access to new services for its vulnerable, isolated residents.  The applicant is also supported by a number of local partners including Charles County Commissioners and the University of Maryland Charles Regional Medical Center, which would provide the project with patient referrals.   
Organization Contact Information: healthpartnersinc.org​

Grantee Organization: Chinese Culture and Community Service Center
Jurisdiction Served: Montgomery County 
Grant and Amount: 19-008 ($150,000) 
Grant Project Description: This project would support a new pain management initiative that is designed to reduce reliance on opioids for chronic pain.  Services would include acupuncture and psychosocial support group sessions based on the Stanford Model of Chronic Disease Self-Management Programs.  The project would also work individually with patients to access their medical and mental condition and develop a care plan to address depression, anxiety, and other psychosocial issues while simultaneously working toward the tapering of medication levels. 
Organization Contact Information: www.ccacc-dc.org/​

Grantee Organization: Family Services
Jurisdiction Served: Montgomery 
Grant and Amount: 19-011 ($300,000) 
Grant Project Description: This project would support an existing multigenerational initiative utilizing a multisectoral approach to address health and social inequities focused on the families in and around the James Daley Elementary School.  The Thriving Germantown Initiative utilizes a collective impact model and multiple intervention strategies to provide services to a highly diverse, low-income community in Germantown.  The Initiative is currently supported with a $250,000 two-year grant from the CHRC scheduled to end June 30, 2019 and leveraged $1.2 million in additional private investment.  One and one-half years into program implementation, the program has served 236 children out of a promised 240 for the two-year grant.  The Initiative is envisioned to be a five-year pilot program and is in the middle of year two.  This proposal requests funding for years three and four to sustain the program.
Organization Contact Information: www.fs-inc.org

Grantee Organization: Talbot County Health Department.
Jurisdiction Served: Talbot 
Grant and Amount: 18-002 ($175,000) 
Grant Project Description: This project would establish a Rural Health Collaborative working across five counties (Queen Anne’s, Kent, Talbot, Caroline, and Dorchester) to improve the integration of clinical, social, and preventative health systems. The Collaborative would focus on improving health care for low-income residents and would develop models for integration that can be duplicated in other rural areas. 
Organization Contact Information: Talbot County Health Department​

Grantee Organization: Prince George’s County Fire/EMS.
Jurisdiction Served: Prince George’s 
Grant and Amount: 18-005 ($175,000) 
Grant Project Description: This Mobile Integrated Health project would 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. 
Organization Contact Information: Prince George's County Fire/EMS​

 Grantee Organization: Wicomico County Health Department/EMS 
Jurisdiction Served: Wicomico 
Grant and Amount: 18-006 ($90,000) 
Grant Project Description: This Mobile Integrated Health project would 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. 
Organization Contact Information: http://www.wicomicohealth.org/index.aspx?pageId=1

Grantee Organization: Esperanza Center
Jurisdiction Served: Baltimore City 
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: www.catholiccharities-md.org/services/esperanza-center/health-center/​

Grantee Organization: Care For Your Health
Jurisdiction Served: Baltimore City 
Grant and Amount: 18-017 ($75,000) 
Grant Project Description: This 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: University of Maryland-Baltimore
Jurisdiction Served: Prince George’s 
Grant and Amount: 17-001 ($1,200,000) 
Grant Project Description: This two-year grant is being used to expand access to primary and preventative care services and promote care continuity in Prince George’s County, an area of Maryland with some of the highest chronic disease burdens in the state that would benefit from increased access to primary care services in the community. The project provides a specific emphasis on low-income individuals who present at the emergency department of the Prince George’s Hospital Center for ambulatory care sensitive conditions and seeks to link these residents with routine and ongoing primary care services at a new center in Cheverly. The project would also deploy the Governor’s Wellmobile to reach patients where they live. CHRC grant funds are being utilized to support the salary costs in the clinic and Wellmobile. 
Organization Contact Information: www.umaryland.edu

Grantee Organization: Health Partners
Jurisdiction Served: Charles 
Grant and Amount: 17-002 ($150,000) 
Grant Project Description: This two-year grant is being used to increase access to primary care services in two sites in Charles County, a rural and underserved area of the state. The project will support continuation of services in Waldorf and establishment of a new site in Nanjemoy.  CHRC grant funds are being used to support salaries at the two sites. 
Organization Contact Information: healthpartnersinc.org

Grantee Organization: Family Services 
Jurisdiction Served: Montgomery 
Grant and Amount: 17-003 ($250,000) 
Grant Project Description: This two-year grant will support the Thriving Germantown initiative, which focuses on increasing access to health and social support services in an underserved, low-income, and diverse community around the James Daly elementary school, a Title I elementary school. The Thriving Germantown initiative utilizes a collective impact model and builds on the 'Promise Neighborhood' concept, which tracks 15 indicators across the cradle-to-grave continuum for low-income families. The Thriving Germantown initiative provides a multisectoral approach to improving both health and educational outcomes and offers the potential to leverage significant additional funding from private philanthropic organizations that may be replicable in other underserved and diverse areas of the state.CHRC grant funds are being used to support staff salaries and other program costs.
Organization Contact Information: www.fs-inc.org

Grantee Organization: Wicomico County Health Department
Jurisdiction Served: Wicomico 
Grant and Amount: 16-009 ($425,000) 
Grant Project Description: This three-year grant is being used to support the opening of a school-based health center (SBHC) in Salisbury. In addition to serving students, the SBHC will be open to the adult staff members of the two schools and provides a new access point for both primary and behavioral health services. Billable services will be billed to Medicaid and third-party insurers. CHRC grant funds are being utilized to support the salary costs of the new SBHC. 
Organization Contact Information: www.wicomicohealth.org

 Grantee Organization: Shepherd’s Clinic
Jurisdiction Served: Baltimore City 
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: La Clinica del Pueblo
Jurisdiction Served: Prince George’s 
Grant and Amount: 16-011 ($300,000) 
Grant Project Description: This three-year grant is being used to support the opening of a new Federally Qualified Health Center site in Hyattsville, Prince George's County, which serves the Langley Park, Hyattsville, Riverdale, Mt. Rainer, and Bladensburg communities, providing access to medical, behavioral health, and other social support services. In August 2015, the applicant secured a FY 2015 New Access Point grant from HRSA to support the new site in Hyattsville and has leveraged additional funding from private foundations. Grant funds are being utilized to support the salary costs of program personnel at the new health center site. 
Organization Contact Information: www.lcdp.org

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 'Reducing avoidable ED visits and promoting care in the community​'). 
Organization Contact Information: www.charlescountyhealth.org​

Grantee Organization: Chinese Culture and Community Service Center
Jurisdiction Served: Montgomery
Grant and Amount: 16-014 ($200,000) 
Grant Project Description: This three-year grant is being utilized to support the relocation and expansion of the Pan Asian Volunteer Health Clinic, which serves the low-income Asian American population in Montgomery County. The clinic will provide primary care, case management, prescription assistance, lab testing, and free screening and vaccinations for Hepatitis B. The Clinic is staffed by volunteer physicians and part-time administrative staff. Grant funding is being utilized to the support the salary costs of program staff.
Organization Contact Information: www.ccacc-dc.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 'Reducing avoidable ED visits and promoting care in the community​')​​. 
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 'Reducing avoidable ED visits and promoting care in the community​')​. 
Organization Contact Information: http://www.medstarunionmemorial.org/

Grantee Organization: Esperanza Center
Jurisdiction Served: Baltimore City 
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: West Cecil Community Health Center 
Jurisdiction Served: Harford County and Cecil County
Grant and Amount: 14-008 (480,000) 
Grant Project Description: This three-year grant supports the opening of a new Federally Qualified Health Center (FQHC) in Harford County. The new FQHC will offer primary care services in West Cecil in a Medically Underserved Area (MUA) between Aberdeen and Havre de Grace. Grant funds are being utilized to support the start-up operational costs of the center. West Cecil Community Center leveraged this grant funding to receive an additional $250,000 from the Weinberg Foundation.
Organization Contact Information: http://www.westcecilhealth.org/

Grantee Organization: Health Care for the Homeless 
Jurisdiction Served: Baltimore City 
Grants and Amounts: 14-009 ($140,000) 
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: Mobile Medical Care Inc. 
Jurisdiction Served: Montgomery
Grants and Amount: 14-010 ($480,000)
Grant Project Description: This three-year grant supported the opening of a new multicultural safety net health clinic in the Aspen Hill neighborhood of Montgomery County. The clinic includes eight exam rooms for adult and pediatric medical care. Grant funding is being utilized to support salary costs of staff as well as equipment and supplies during the start up for the clinic. Mobile Medical Care Inc. leveraged this grant funding to receive $900,000 in Federal New Access Point funds and to become designated as a Federally Qualified Health Center.
Organization Contact Information: www.mobilemedicalcare.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 'Reducing avoidable ED visits and promoting care in the community​').
Organization Contact Information: www.healthcareaccessmaryland.org

Grantee Organization: Access Carroll
Jurisdiction Served: Carroll County
Grant Amount: 14-015 ($125,000) 
Grant Project Description: This one-year grant program supports the promotion of the long-term financial sustainability of the grantee, from a grant based billing model to billing both Medicaid and private payors. Grant funds are being utilized to hire a full time biller/coder and consultant help to design and implement billing systems and enhance the use of its IT system. 
 (The grant is also listed in​ 'Expanding Safety Net Capacity')
Organization Contact Information: www.accesscarroll.org​

Grantee Organization: Health Partners
Jurisdiction Served: Charles County
Grant Amount: 14-016 ($300,000) 
Grant Project Description: This three-year grant assists this free clinic as it transitions from a grant based billing model to billing both Medicaid and private payors. Grant funds are being utilized to support the salary costs of four new health clinicians in a patient-centered medical home model. (The grant is also listed in 'Expanding Safety Net Capacity' ).
Organization Contact Information: www.healthpartnersinc.org​

Grantee Organization: Allegany County Health Department 
Jurisdiction Served: Allegany 
Grant and Amount: LHIC13-001 ($185,048) 
Grant Project Description:  This proposal seeks to reduce health disparities and address social determinants of health by deploying community health workers to link patients to community resources.  Grant funds would be utilized to create a community resource guide, to support cultural competency provider training, and to provide access to subsidized transportation services. 

Grantee Organization: Howard County Local Health Improvement Coalition
Jurisdiction Served: Howard 
Grant and Amount: LHIC13-002 ($250,000) 
Grant Project Description:  This proposal seeks to increase access to health care and enhance chronic disease prevention by utilizing “hotspotting” data analysis and targeting resources to address the complex health needs of individuals identified in this analysis. Grant funds will be utilized to establish a community health worker program; increase the number of PCMHs in the community; and create shared savings blueprint. 

Grantee Organization: Tri-County/Worchester County Health Department
Jurisdiction Served: Worcester, Wicomico, Somerset 
Grant and Amount: LHIC13-003 ($250,000) 
Grant Project Description:  This proposal targets diabetes-related hospital ED visits and develops a comprehensive care coordination model to link frequent ED users with access to primary care services in the community. The model leverages community partnerships and addresses social determinants of health in the Lower Shore. Grant funds would be utilized to develop and implement regional diabetes care management teams to assist diabetic patients in gaining access to a range of health care and social support resources. ​

Grantee Organization: Cecil County Health Department (Cecil County Community Health Advisory Committee) 
Jurisdiction Served: Cecil 
Grant and Amount: LHIC13-004 ($120,000) 
Grant Project Description:  This proposal seeks to reduce behavioral health-related visits to Union hospital related by embedding a nursing case management program in the hospital to link patients with services in the community. The grant would also support a mobile mental health crisis program in Cecil County, which is supported by Cecil County Government (in addition to CHRC grant funding). 

Grantee Organization: The Partnership for a Healthier Charles County
Jurisdiction Served: Charles 
Grant and Amount: LHIC13-005 ($125,000) 
Grant Project Description: This proposal seeks to expand access to primary care services in an underserved area in western Charles County and utilizes CHRC grant funds to establish a new Patient-Centered Medical Home (PCMH) in Nanjemoy. 

Grantee Organization: Harford County Health Department
Jurisdiction Served: Harford 
Grant and Amount: LHIC13-007 ($200,000) 
Grant Project Description:  This proposal seeks to improve overall health outcomes for high-risk residents by providing comprehensive coordinated care and preventative mental health services to decrease ED utilization. Grant funds would be utilized to hire three “clinical nurse social workers” and to expand the Comprehensive Women’s Health Project care coordination model to 3 additional sites. 

Grantee Organization: Calvert Memorial Hospital
Jurisdiction Served: Calvert
Grant and Amount: LHIC12-006 ($50,000) 
Grant Project Description: The Calvert County Health Improvement Roundtable utilized grant funds to form a collaborative, comprehensive community care coordination team with faith and community-based organizations and local health system providers to target a reduction in diabetes emergency room visits by the African American population.  CHRC grant funding supports development of a “Diabetes Boot Camp” designed to educate patients about monitoring blood sugar levels and maintaining normal blood sugar levels. 

Grantee Organization: Charles County Health Department
Jurisdiction Served: Charles
Grant and Amount: LHIC12-009 ($25,000) 
Grant Project Description: The Charles County Health Department utilized grant funds to initiate projects targeting chronic disease and obesity in adults and children.  Grant funding supported a resident education campaign that utilized community events, pediatrician offices, and billboards.  In addition, grant funding was used to develop educational and outreach materials that were used at events held throughout the year to educate and engage the residents on the health risk factors for cardiovascular disease and obesity. 

Grantee Organization: Frederick County Health Care Coalition
Jurisdiction Served: Frederick
Grant and Amount: LHIC12-010 ($25,000) 
Grant Project Description: The Frederick County Health Care Coalition’s Local Health Improvement Plan focused on six priorities identified by community stakeholders in October 2011: 1) mental health, 2) affordable dental care, 3) access to care, 4) wellness and prevention, 5) health inequities, and 6) early childhood growth and development.  The CHRC grant funding was utilized to support strategies to address each of these priority areas, such as supporting the development of a suicide prevention kit to promote depression screening by pediatricians, providing education and resources to address the health care needs of residents with limited English proficiency, and providing direct care coordination services to individuals most in need of health care. 

Grantee Organization: The Howard County Local Health Improvement Coalition
Jurisdiction Served: Howard
Grant and Amount: LHIC12-013 ($25,000) 
Grant Project Description: The Howard County Local Health Improvement Coalition utilized grant funding to support efforts to strengthen the coordination and collaboration among community providers and other resources to more effectively address access to health care and behavioral health services and to encourage people to achieve and maintain a healthy weight.  Grant funds supported the implementation of three projects: (1) a Biennial Health Survey, jointly sponsored with the Horizon Foundation, to gather baseline ethnic health information not previously collected; (2) the development of “Sugar Sweetened Beverage Campaign,” a marketing campaign aimed at reducing sugar sweetened beverage consumption, jointly sponsored by the Horizon Foundation; and (3) a Behavioral Health Inventory to improve understanding of the referral and release processes of three behavioral health major providers

Grantee Organization: Montgomery County Department of Health and Human Services
Jurisdiction Served: Montgomery
Grant and Amount: LHIC12-014 ($25,000) 
Grant Project Description: The Montgomery County Health Improvement Coalition utilized grant funds to establish six workgroups to address the six priorities for community health improvement; (1) Behavioral health, (2) Cancers, (3) Cardiovascular disease, (4) Diabetes, (5) Maternal and infant Health, and (6) Obesity.  These workgroups are tasked with developing, executing and evaluating action plans targeting the priority areas. utilized grant funding to support two workgroups, of their existing coalition, Healthy Montgomery. 

Grantee Organization: Prince George’s Healthcare Action Coalition
Jurisdiction Served: Prince George’s
Grant and Amount: LHIC12-015 ($25,000) 
Grant Project Description: The Prince George's Healthcare Action Coalition utilized grant funding to address several goals of the Coalition: health care access, chronic disease, birth outcomes, and infectious diseases.  Grant funds were utilized for the following strategies: (1) to develop a safety net services directory to inform low-income and uninsured residents about options for accessing primary and specialty care services in the community; (2) to expand HIV/AIDS outreach and prevention education efforts to include the use of social media technology, promoting culturally sensitive messages to educate the public about HIV prevention. 

Grantee Organization: St Mary’s County Health Department
Jurisdiction Served: St Mary’s
Grant and Amount: LHIC12-016 ($25,000) 
Grant Project Description: The St. Mary's County Health Department utilized grant funds to implement a smoking cessation social marketing campaign targeted low-income residents of St. Mary’s County.  Grant funds supported staffing costs and overall efforts to recruit local employers willing to adopt tobacco free work places throughout the jurisdiction.  In addition, the St. Mary’s LHIC has been working to develop county-wide policies to create tobacco free government facilities and public areas. 

Grantee Organization: Washington County Health Department
Jurisdiction Served: Washington
Grant and Amount: LHIC12-017 ($25,000) 
Grant Project Description: The Washington County Health Department utilized grant funds to complete a comprehensive community needs assessment to identify gaps and barriers related to accessing health care in the County.  A needs assessment had not been conducted in Washington County for more than 10 years.   The needs assessment was completed, and identified the following three priority areas: (1) reduce behavioral health ED visits; (2) reduce diabetes related ED visits; and (3) reduce cardiovascular disease related ED visits.

Grantee Organization: Community Clinic, Inc.
Jurisdiction Served: Montgomery
Grant and Amount: 12-008 ($280,000)
Grant Project Description: This two-year grant expanded services for high-risk patients in Montgomery and Prince George’s Counties by supporting the integration of Community Health Workers and other staff into its primary care clinical program. CHRC grant funding was utilized to enhance Community Clinic Inc.’s (CCI) electronic medical records system and support the salaries of program staff. The grantee reported serving over 4,919 individuals through 10,680 visits. CCI leveraged this grant funding to receive $1,926,000 in federal and private funding.
Organization Contact Information: www.cciweb.org

Grantee Organization: Catholic Charities-Esperanza Center
Jurisdiction Served: Baltimore City
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
Jurisdiction Served: Baltimore City
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: Greater Baden Medical Services
Jurisdiction Served: Charles, Prince George's and St. Mary's
Grant and Amount: 11-012 ($200,000) 
Grant Project Description: This one-year grant supported the delivery primary care services at a new location in Waldorf, Md. Grant funds supported the salaries of primary care staff in the center's initial year of operations. The grantee reported serving 578 patients and providing over 1,600 patient visits over the duration of the grant.
Organization Contact Information: www.gbms.org/

Grantee Organization: Anne Arundel Medical Center
Project Name: Anne Arundel Medical Center's Community Health Center
Jurisdiction Served: Anne Arundel
Grant and Amount: 11-013 ($150,000) 
Grant Project Description: This three-year grant supported the expansion of access to primary care services at a new health care clinic in Anne Arundel County. The clinic offered primary care, specialty and diagnostic referrals, case management, and bilingual services on a sliding-fee scale. Grant funds were utilized to support operation and administrative costs for expansion of services. The grantee reported serving 6,168 patients and provided over 21,000 visits over the duration of the grant.
Organization Contact Information: http://www.aahs.org/healthcenter/index.php

Grantee Organization: Calvert Healthcare Solutions
Jurisdiction Served: Calvert
Grant and Amount: 11-014 ($225,000) 
Grant Project Description: This three-year grant expanded the grantee’s capacity to provide primary health care services and linkage to other service supports in Calvert County.  The grant supported an increase in service hours for primary care and mental health services, the creation of a formal referral consortium with community agencies, and an increase in access to prescription assistance programs. Grant funds were utilized to support salaries for expanding the program. The grantee reported serving 493 patients through 3,311 visits over the duration of the grant.
Organization Contact Information: http://www.calverthealthcare.org

Grantee Organization: Baltimore City Health Department
Jurisdiction Served: Baltimore City
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: http://health.baltimorecity.gov/

Grantee Organization: Baltimore County Health Department
Jurisdiction Served: Baltimore County
Grant and Amount: 09-003 ($55,450) 
Grant Project Description: This one-year grant supported the health department’s efforts to enhance the information technology capacities in the health department's school-based wellness centers, and to expand services by opening a school-based wellness center in Dundalk. Grant funds were utilized to upgrade the computers systems at the SBHCs. The new computers and other upgraded equipment paid for with this funding enabled the SBHC to keep more complete and accurate patient records with an ultimate goal of being able to bill for health care services rendered.
Organization Contact Information: www.baltimorecountymd.gov/agencies/health

Grantee Organization: Coppin State University/Helene Fuld School of Nursing
Jurisdiction Served: Baltimore City
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: Dorchester Health Department
Jurisdiction Served: Dorchester
Grant and Amount: 09-005 ($220,000 
Grant Project Description: This two-year grant supported the operations of a school based health center in Dorchester County. Grant funds were utilized to support staff salaries at the center as well as to assist administrative personnel in making the program more sustainable through increased billing and maximizing reimbursement. The grantee reported serving more than 860 students and providing more than 2,700 clinical and mental health services over the duration of the grant.
Organization Contact Information: www.dorchesterhealth.org

 Grantee Organization: Frederick Health Department
Jurisdiction Served: Frederick
Grant and Amount: 09-006 ($464,785)
Grant Project Description: This two-year grant supported the opening of the Hillcrest Elementary school based health center in 2009.This grant supported primary care services, links for students and families to medical homes, oral health screenings and dental fluoride varnishes. In 2011, the Frederick County Health Department transferred this grant to the Frederick Community Action Agency (FCAA), which expanded the program to two additional schools in the jurisdiction; Lincoln Elementary and Waverly Elementary and linked students and families in need of care to FCAA's clinic.
Organization Contact Information: www.cityoffrederick.com/Index.aspx?NID=183

Grantee Organization: Harford Health Department
Jurisdiction Served: Harford
Grant and Amount: 09-007 ($145,749)
Grant Project Description: This two-year grant supported a school based health center program at four elementary schools in the county. The CHRC's grant supported expansion of primary care and mental health services at the SBHCs for students and their families, particularly those lacking access to care. Grant funds were utilized for administrative costs and to support Community Health Service Evenings, which provided free health screenings, physicals and assisted linking individuals and families to a medical home. The grantee reported that 1,474 patients received care through the program.
Organization Contact Information: www.harfordcountyhealth.com

Grantee Organization: Montgomery County Department of Health and Human Services
Jurisdiction Served: Montgomery
Grant and Amount: 09-008 ($224,100)
Grant Project Description: This two-year grant supported the expansion of health care and preventative dental services at four of the school based health centers in the county. Funds supported the purchase of equipment and the provision of fluoride varnishes to children in the school system. The grantee reported nearly 900 students were served through 1,420 primary cares visits and more than 1,700 fluoride varnish applications over the duration of the grant.
Organization Contact Information: www.montgomerycountymd.gov/hhstmpl.asp

Grantee Organization: Washington County Health Department
Jurisdiction Served: Washington
Grant and Amount: 09-009 ($216,000) 
Grant Project Description: This two-year grant supported the expansion of mental health services at the health department's three School-Based Health Centers. The grant funds enabled the expansion of patient access to a licensed social worker. The grant also helped to support the evaluation and implementation of a software system to improve student/patient tracking and improve billing and collections for services. The grantee reported serving 183 students through 1,069 visits over the duration of the grant.
Organization Contact Information: http://washco-md.net/human/index.shtm

Grantee Organization: Muslim Community Center
Jurisdiction Served: Montgomery
Grant and Amount: 09-015 ($240,000) 
Grant Project Description: This two-year grant allowed expansion of a diabetes treatment program in the community center. Grant funds supported primary and specialty care for diabetic patients and worked with patients to receive diabetic education and regular tests such as HbA1c and retina exams. Grant funds supported the staff salaries for clinic staff. In 2011 MCC was the recipient of clinical staff from Kaiser Permanente’s Community Ambassadors Program, which sustained the Clinic's expanded capacity and diabetes program for an additional three years. The grantee reported serving 2,296 patients through 20,616 visits over the duration of the grant.
Organization Contact Information: Muslim Community Center - Medical Clinic​

Grantee Organization: Primary Care Coalition of Montgomery
Jurisdiction Served: Montgomery
Grant and Amount: 09-016 ($375,000)
Grant Project Description: The CHRC grant supported the Montgomery Cares program through the development of a Specialty Treatment Access Team which provided care coordination and case management services for the most complex specialty care patients. The grant also supported the Specialty Care Workgroup which focused on high-level change, coordination, and policy development to identify system level barriers to care and creating sustainable access to specialty care. Grant funds provided linkages and the specialty care referral process between safety net providers, care coordinators, and specialty care physicians.
Organization Contact Information: www.primarycarecoalition.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 'Reducing avoidable ED visits and promoting care in the community​').
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 'Reducing avoidable ED visits and promoting care in the community​'). 
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 'Reducing avoidable ED visits and promoting care in the community​'). 
Organization Contact Information: http://www.uchs.org/

Grantee Organization: Greater Baden Medical Services
Jurisdiction Served: Prince George's 
Grant and Amount: 08-025 ($500,000) 
Grant Project Description: This three-year grant supported the opening of a new health center in Brandywine, MD, as well as the expansion of primary care and prenatal services at GBMS’s Capitol Heights, MD facility. Grant funds supported the salaries of clinical and support staff and to purchase necessary equipment and supplies. This program served 3,519 individuals and provided over 6,000 visits over the duration of the grant.
Organization Contact Information: www.gbms.org/

Grantee Organization: Mobile Medical Care Inc. 
Jurisdiction Served: Montgomery
Grant and Amount: 08-026 ($500,000)
Grant Project Description: This three-year grant supported increased access to primary care and integration of behavioral health care services in a model that leverages grant funding with existing County resources. The grant funds enabled MobileMed to open a new primary care clinic in Rockville which was co-located with existing behavioral health care services provided by Montgomery County. The grantee reported that the clinic provided services to over 5,791 patients through 12,641 visits over the duration of the grant.
Organization Contact Information: www.mobilemedicalcare.org/

Grantee Organization: Access Carroll
Jurisdiction Served: Carroll County
Grant and Amount: 07-001 ($100,000)
Grant Project Description: This one-year grant supported an expansion of care coordination to ensure timely referrals for specialty care services and improve the organization’s overall efficiency. Grant funding was utilized to support the staff salaries. Over the one-year grant period, Access Carroll was able to care for 594 new patients and increase their volunteer specialty provider referral network by 34 physicians for a total of 62 providers.
Organization Contact Information: www.accesscarroll.org

Grantee Organization: Baltimore Medical System
Jurisdiction Served: Baltimore City
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: Calvert Memorial Hospital
Jurisdiction Served: Calvert County
Grant and Amount: 07-004 ($500,000)
Grant Project Description: This three-year grant supported  improving access to health care services for low-income and uninsured residents of Calvert County by increasing the capacity of the Twin Beaches Community Health Center, increasing access to the case management and providing supplemental payments to specialists and an area pharmacy to cover the gap between patients sliding fee scale payments and actual costs. This program provided services to 898 patients with 6,500 visits over the duration of the grant.
Organization Contact Information: www.calverthospital.com

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 'Reducing avoidable ED visits and promoting care in the community​').
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 'Reducing avoidable ED visits and promoting care in the community​').
Organization Contact Information: www.cityoffrederick.com/Index.aspx?NID=183​

Grantee Organization: Health Partners, Inc. 
Jurisdiction Served: Charles County
Grant and Amount: 07-007 ($500,106) 
Grant Project Description: This three-year grant supported expanding the capacity of the grantee’s capacity to serve low-income un/underinsured residents in Charles County. Grant funds were utilized to support clinical staff salaries.  The grantee reported that there was a 300% increase the clinic's capacity, during the program, with over 3,300 patients served. Health Partners leveraged their CHRC grant with a number of other private and local organizations, raising $296,000 in additional grant funding, including more than 3,100 volunteer hours donated by physicians, specialists and other health care professionals.
Organization Contact Information: www.healthpartnersinc.org

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