Promoting Food Security, Reducing Obesity, and Addressing Diabetes

Promoting Food Security, Reducing Obesity, and Addressing Diabetes is sponsored by Maryland Department of Health. This grant program supports initiatives in various Maryland jurisdictions to address food security, reduce obesity, and combat diabetes.

Maryland Department of Health grantee_childhood obesity Accessibility Information ​Promoting Food Security, Reducing Obesity, and Addressing Diabetes (45 grants)​ Grantee Organization: Healthcare for the Homeless Jurisdiction Served: Baltimore City​ Grant and Amount: 23-08 ($390,000) The program will expand access to care for unhoused and housing insecure individuals, primarily racial and ethnic minorities, living in Baltimore City and impacted disproportionately by diabetes, hypertension, heart disease, and comorbidities such as obesity.

The program will provide 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: Associated Catholic Charities – Esperanza Center Jurisdiction Served: Baltimore City Grant and Amount: 23-07 ($115,900) The program will expand 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 will provide clients point of care phlebotomy and screening services, focusing on screening and management of chronic diseases. Grantee Organization: Shepherd's Clinic Jurisdiction Served: Baltimore City Grant and Amount: 23-06 ($280,000) The TRI UMPH program will address racial disparities related to diabetes facing uninsured and underinsured adults in Baltimore City.

Through the TRI UMPH program, Shepherd's Clinic will provide: (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: 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: Food & Friends Jurisdiction Served: Washington County Grant and Amount: 23-03 ($150,000) The program will address health disparities related to diabetes among the African American population in Washington County. Food & Friends will deliver Medically Tailored Meals and Medical Nutrition Therapy to homes of individuals who are too ill to shop or cook for themselves and have diabetes with A1C>8%.

Grantee Organization: Maryland Living Well Center Agency on Aging Jurisdiction Served: Eastern Shore Grant and Amount: 23-02 ($300,000) The program will improve diabetes management and expand access to care for low-income, elderly, and racial and ethnic minority individuals living on the Eastern Shore.

Maryland Living Well Center will provide Social Determinants of Health (SDOH) screenings, identify social service needs, and enroll older adults with or at high risk for diabetes and other chronic conditions into evidence-based disease management programs.

Grantee Organization: Medstar Franklin Square Hospital Jurisdiction Served: Baltimore County Grant and Amount: 23-01 ($360,000) The program seeks to address disparities in chronic disease and food access, as well as other disparities faced by African American residents in Baltimore City and Baltimore County.

MedStar Franklin Square Hospital will provide healthy food for patients to prepare nutritious meals for their families, connect patients to a dietician and Community Health Advocate, and provide 20 hours of health education. Through the Primary Care Center and Family Health Center, patients will have access to primary care, specialty care, prevention services, and behavioral health assistance.

Grantee Organization: Access Art Jurisdiction Served: Baltimore City Grant and Amount: 22-17 ($120,000) This project looks to continue the applicant's current food distribution events and comprehensive health that address multiple SDOH in the Morrell Park neighborhood of southwest Baltimore.

Grant funding will cover the salary costs for one CHW who will provide assistance to families to access health insurance benefits, behavioral health services, and family assistance programs.

Grantee Organization: Mobile Medical Care Jurisdiction Served: Montgomery County Grant and Amount: 22-08 ($500,000) This project will expand access to behavioral health, primary care, and chronic disease management services for African diaspora residents of east Montgomery County.

Key interventions include conducting outreach at community events and through peer advocates, training peer advocates in Mental Health First Aid, and case management. MobileMed will facilitate connections to services to address SDOH including food insecurity and vocational skills. Partners will provide referrals and manage CHWs.

Grantee Organization: Greater Baltimore Medical Center Jurisdiction Served: Baltimore City Grant and Amount: PW-22-06 ($1,500,000) This project will address 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 (zip codes 21202 and 21218).

Key interventions include an expansion of the number of patients treated at GBMC Jonestown Clinic, where patients will 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 to address Social Determinants of Health (SDOH) needs.

The project will also conduct public screenings and education at community events, and healthy lifestyle interventions such as community walks/runs, education workshops, patient support groups, peer challenges to support water and protein intake goals, and healthy cooking demonstrations.

Grantee Organization: Primary Care Coalition Jurisdiction Served: Montgomery County Grant and Amount: 22-06 ($375,000) This project will expand comprehensive medical and SDOH supports among minority populations in Montgomery County.

The Nexus Connect program uses CHWs to address individuals' health (health screenings, access to primary care, health insurance navigation, prescription medication assistance, healthy behaviors), food security, English language (ESOL classes), job readiness, legal aid, subsidized childcare, education gaps (kindergarten readiness, HS diploma/GED, college/trade school pathways, career building), and economic empowerment (financial literacy, budgeting) needs.

CHWs, called “JEDIs," will provide health and social service navigation, partner referrals, and partner organization coordination. Grantee Organization: Sinai Hospital Jurisdiction Served: Baltimore City Grant and Amount: 22-01 ($360,000) The project seeks to address 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) will be 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 will screen individuals for somatic and behavioral conditions, provide linkages to care and wraparound services, and deliver case management including one-on-one wellness planning.

Grantee Organization: Prince George's County Health Department Jurisdiction Served: Prince George's County Grant and Amount: PW-22-08 ($1,600,000) This project will address disparities in heart disease and diabetes in the Capitol Heights, Bladensburg, Hyattsville, and Riverdale areas (zip codes 20710, 20737, 20743, and 20785).

Key interventions include Community Health Worker (CHW)-driven outreach and care coordination, bi-directional e-referrals among health and social service providers, and technical assistance to improve providers' ability to bill for care coordination. The project will promote delivery of culturally and linguistically sensitive services, and utilize EMR, CRISP, and telehealth services including through telehealth hubs.

Targeted outcomes include reductions in disparities related to heart disease and diabetes, improved diabetic control as measured by A1c or blood glucose levels, and increased access to primary care.

Grantee Organization: La Clínica del Pueblo Jurisdiction Served: Montgomery & Prince George's Counties Grant and Amount: PW-22-085($1,500,000) This project will address disparities in diabetes for the Hispanic population in areas of Montgomery and Prince George's Counties (zip codes 20703, 20706, 20710, 20712, 20722, 20737, 20740, 20770, 20781, 20782, 20783, 20784, 20785, 20901, 20903, and 20912).

Interventions will include remote diabetes monitoring, peer-led diabetes self-management, diabetes health screenings via the Luminis mobile clinic, navigation to primary care, addressing barriers to access such as lack of insurance and transportation, access to fresh produce, peer-led walking groups, health system navigation and legal services support, medical interpretation, and a comprehensive community health education, awareness and outreach campaign.

Grantee Organization: TidalHealth Jurisdiction Served: Wicomico & Worcester Counties Grant and Amount: PW-22-02 ($1,100,000) This project will address disparities in diabetes experienced by the Black and Haitian population on the Lower Shore (zip codes 21801, 21804, 21822, 21853, 21851, and 21863).

Key interventions identified include expansion of Mobile Integrated Health, connections with primary care, expansion of culturally linguistic and evidenced based diabetes programming, and deployment of CHWs. Target outcomes include reduced rates of uncontrolled diabetes and hypertension among Black adults (18+) in the prioritized zip codes.

Grantee Organization: Horizon Goodwill Industries Jurisdiction Served: Washington County Grant and Amount: PW-22-07 ($925,000) This project will address health disparities in diabetes and mental health in the Hagerstown area (zip code 21740).

The project will provide on-site access to dietary and diabetic educators, healthcare navigation, wrap-around case management, and job training services; walk-in testing for diabetes (HgA1c) and retinal neuropathy; and referrals to mental health services. The goal is to decrease the rate of ED utilization for ambulatory care sensitive conditions, improve management of diabetes, and help reduce the rate of new diabetes diagnoses.

​ ​ Grantee Organization: MedStar Good Samaritan Jurisdiction Served: Baltimore City Grant and Amount: 21-001 ($93,000) Grant Project Description: The Good Samaritan Hospital Food Farmacy Program is designed for adult patients with Type 2 Diabetes who may also have heart failure and/or food insecurity.

Eligible patients receive ongoing one-on-one care and consultations by a Community Health Advocate (CHA) and dietitian, and customized healthy food at no cost. The Good Samaritan Collaborative Care Center offers 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 connects patients to holistic health resources in the community. Organization Contact Information: https://www. medstarhealth.

org/locations/medstar-good-samaritan-hospital Grantee Organization: Luminis Health Anne Arundel Medical Center (LHAAMC) Jurisdiction Served: Anne Arundel & Prince George’s Counties Grant and Amount: 21-002 ($90,000) Grant Project Description: This program supports the expansion of existing Diabetes Prevention Program (DPP) cohorts run by the health system to a broader population of underserved and vulnerable communities, particularly Hispanic populations.

The grantee is using their mobile clinic to deliver health education and screening services to areas that lack access to primary care providers and/or transportation. The program is using bilingual community educators and Community Health Workers (CHWs) for outreach and delivery of education programs on the mobile clinic, and to recruit and attract residents to the DPP classes.

The mobile clinic also provides some limited screenings (e.g., A1C, blood glucose, blood pressure). Educational programs promote healthy eating, healthy lifestyle changes, and the importance of physical activity in preventing disease. The goal is to anchor members of the target communities to a medical home.

Organization Contact Information: https://www. aahs.

org/ Grantee Organization: Korean Community Services Center (KCSC) Jurisdiction Served: Montgomery & Prince George’s Counties Grant and Amount: 21-003 ($170,000) Grant Project Description: The KCSC Diabetes Self-Management for Asian Americans program targets low-income Asian Americans residing in Montgomery and Prince George’s Counties, particularly Chinese/Korean immigrants over 55 and their family members, as well as underserved communities with limited English proficiency who face cultural barriers to care.

KCSC is adapting the Self-Management Resource Center's Chronic Diseases Self-Management Program, including the Diabetes Self-Management Program, which uses a community-based participatory approach to improve health status, increase healthy behavior and self-efficacy, reduce healthcare costs, and decrease emergency room visits.

KCSC is partnering with Mobile Medical Care, Inc., Chinese Cultural and Community Service Center, the Korean American Medical Association, the Self-Management Resource Center, and LabCorp to administer the program. Organization Contact Information: http://www. kcscgw.

org/ Grantee Organization: Baltimore Medical System Jurisdiction Served: Baltimore City Grant and Amount: 21-004 ($225,000) Grant Project Description: This program will support the BMS Diabetes Education and Lifestyle Change (BMS DEAL) program by adding a Certified Diabetes Educator and Care Specialist (CDECS) to the multidisciplinary care team at the Saint Agnes and Pine Heights community health centers.

The specialist will educate patients about diabetes self-management, helps them set behavioral goals to improve diet, and manages their weight to improve diabetic control and achieve better health outcomes. The specialist also will identify and address social barriers to accessing healthy food and complying with regular provider checks.

The BMS DEAL is an integrated approach to diabetes care which includes the patient, provider, medical assistant, nurse, and pharmacist when indicated for patient education, testing and follow-up. The clinics (St. Agnes & Pine Heights Health Centers) work with several community partners to address food insecurity and transportation barriers.

Organization Contact Information: https://bmsi. org/ Grantee Organization: Chase Brexton Jurisdiction Served: Howard County Grant and Amount: 21-005 ($325,000) Grant Project Description: This program expands the Chase Brexton patient-centered medical home model of chronic disease management for adults diagnosed with diabetes.

Grant funding is expanding Chase Brexton’s capacity to provide treatment and ancillary support services to adults diagnosed with diabetes and provide intensive patient‐centered care and treatment adherence support to those diagnosed with “uncontrolled” diabetes, defined as having an A1c greater than 9%.

The program is enhancing the delivery of comprehensive diabetes-focused treatment, increasing health literacy surrounding diabetes treatment, improving self-management skills, and encouraging healthier eating habits. The program also works to reduce diabetes-related health disparities for 90 low-income, un/underinsured, and underserved residents of Howard County, including racial and ethnic minorities.

Organization Contact Information: https://chasebrexton.

org/ Grantee Organization: Holy Cross Health Jurisdiction Served: Montgomery & Prince George’s Counties Grant and Amount: 21-006 ($60,000) Grant Project Description: The Holy Cross Equitable Wellness Initiative addresses chronic disease prevention and management of type 2 diabetes and pulmonary rehabilitation post COVID-19 to decrease disparities in care among African American and Latinx populations.

The initiative focuses on behavior change, education, and self-efficacy through implementation of three culturally appropriate health education programs developed for populations with low educational attainment and health literacy.

Participants will receive a weekly session with Health and Wellness Coaches to discuss the status of goals and identify and address expressed social needs through referrals using an established free or reduced cost social care service network. To incentivize completion of the three-part series, each participant will receive a box of fresh produce. Organization Contact Information: https://www.

holycrosshealth.

org/location/holy-cross-health-center-silver-spring Grantee Organization: Associated Catholic Charities – Esperanza Center Jurisdiction Served: Baltimore City, Baltimore County, and Anne Arundel County Grant and Amount: 21-007 ($125,000) Grant Project Description: The “Diabetes and Dignidad” program will employ a bilingual community health worker (CHW) to staff up to 70 community-based diabetes rapid A1c testing events annually for Latinx residents located in parts of Baltimore City, Baltimore County, and Anne Arundel County.

All newly diagnosed diabetics who are uninsured and uninsurable will be referred to primary care and the Diabetes Self-Management Program at Esperanza. Individuals diagnosed with pre-diabetes will receive health information on managing the condition with a list of health care providers for further screening.

The CHW also will provide diabetes self-management support, food security screening, and home visits to participants of Esperanza’s existing diabetes program. Organization Contact Information: https://www. catholiccharities-md.

org/services/esperanza-center/ Grantee Organization: UMD – St. Joseph’s Medical Center Jurisdiction Served: Baltimore County Grant and Amount: 21-008 ($50,000) Grant Project Description: This program supports the hiring of one additional licensed FTE (a Community Health Worker) to coordinate and manage community outreach and to expand the chronic disease education programs.

Funding also helps cover the cost of home self-monitoring equipment (e.g., scale, pulse oximeter, thermometer, BP cuff, and blood glucose monitoring device) for individuals who are uninsured or unable to cover the cost of insurance co-pays. Organization Contact Information: https://www. umms.

org/sjmc Grantee Organization: West Cecil Health Center Jurisdiction Served: Cecil and Harford Counties Grant and Amount: 21-009 ($130,000) Grant Project Description: This program supports procurement and implementation of Health Information Technology in the form of a clinical health dashboard and the salary of full-time Data Analytics employee.

The clinical health dashboard is used to perform risk stratification of identified vulnerable and at-risk patients. A Nurse Case Manager then follows-up with these individuals, provides case management, and works with community partners to provide linkages to chronic disease management resources and care.

West Cecil works with community partners in screening and identifying vulnerable and at-risk individuals with uncontrolled hypertension and diabetes to improve clinical outcomes. Organization Contact Information: http://www. westcecilhealth.

org/​ Grantee Organization: MedStar Montgomery Hospital Jurisdiction Served: Montgomery County Grant and Amount: 21-011 ($125,000) Grant Project Description: This program promotes access to health services and support for anti-poverty programs focusing on under-resourced Latino families in central Montgomery County.

The program aims to address unmet health and social service needs, provide food security and education, and promote health literacy around COVID transmission. Funding covers the salary costs for two new bi-lingual FTEs, an ED navigator and community health advocate, and other costs to be borne by the hospital, which include EMR modification, travel, and education materials, and a partial FTE at Proyecto Salud to co-locate clinic space.

Organization Contact Information: https://www. medstarhealth.

org/locations/medstar-montgomery-medical-center Grantee Organization: La Clinica del Pueblo Jurisdiction Served: Prince George’s County Grant and Amount: 21-014 ($108,000) Grant Project Description: This program seeks to ameliorate the impact of COVID on the Latino community through several strategies that include a partnership with the Prince George's County Food Equity Council and FRESHFARM, increasing the organization’s referral network to social services, providing health education, promoting socially distanced walking groups, peer-navigation of services, and food distribution.

Organization Contact Information: https://www. lcdp. org/ Grantee Organization: Primary Care Coalition Jurisdiction Served: Montgomery County Grant and Amount: 21-015 ($160,000) Grant Project Description: This program introduces food security screenings at three “point of entry” sites and provides referrals to an existing program that serves children from newly arrived immigrant families.

The additional "points of entry" for children and households include school mental health providers and a food distribution program operating from a school site. Organization Contact Information: https://www. primarycarecoalition.

org/ Grantee Organization: United Way of Central Maryland Jurisdiction Served: Baltimore City Grant and Amount: 21-017 ($93,000) Grant Project Description: This program addresses 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 will cover 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 have been transformed into comprehensive health markets that address multiple SDOH. A bilingual CHW will provide case management and social services support.

Longer term, the CHW will convene a team of residents and food experts to plan strategically how to increase the number of sustainable food providers locally. Organization Contact Information: https://www. uwcm.

org/ Grantee Organization: Western Maryland Health Care Center (dba Mountain Laurel) Jurisdiction Served: Allegany & Garrett Counties Grant and Amount: 21-026 ($180,000) Grant Project Description: The program expands the current diabetes prevention program (ADAPT – Appalachia Diabetes Awareness Prevention Program) by adding a new mobile medical unit to meet residents "where they live, work and play" to provide nutrition, diabetes, and weight management education.

Individuals at-risk/pre-diabetics are referred to the accredited Diabetes Prevention Program at Garrett Regional or AHEC West; individuals with active, uncontrolled diabetes are referred to Mt Laurel's chronic care management teams. The program addresses two key SDOH by tapping its 340B pharmacy for low-income patients and providing transportation via two full-time van drivers. Organization Contact Information: https://www.

wmhs. com/ Grantee Organization: Moveable Feast Grant and Amount: 20-019 ($170,000) Jurisdiction Served: Statewide Grant Project Description: Moveable Feast seeks to serve vulnerable, low-income, homebound diabetic clients.

The grant will support expansion of the currently successful program that delivers free medically-tailored meals to vulnerable homebound individuals who have prediabetes or diabetes and other chronic conditions, and experience food insecurity and malnutrition. Clients will also be offered medical nutrition therapy courses, and the beneficial effects of increased social contacts with Moveable Feast staff and volunteers.

Organization Contact Information: Moveable Feast Grantee Organization: Food & Friends, Inc. Grant and Amount: 20-020 ($120,000) Jurisdiction Served: Statewide Grant Project Description: Grant funds will support Food & Friends' current home-delivered medically-tailored free meals program for individuals identified by MedStar Family Choice and MedStar Health with Type II diabetes, food insecurity, malnutrition, and limitations of Activities of Daily Living.

The program aims to continue to build the case for coverage by public and private payors to address social determinates of health. The applicant navigates clients toward the Supplemental Nutrition Assistance Program (SNAP) and publicly funded health insurance. Transportation and nutrition education barriers are overcome through the delivery of meals.

The volunteer delivery mechanism and 'case for coverage' are the primary sources of sustainability and there is strong endorsement from MedStar Family Choice MCO.

Organization Contact Information: Food & Friends, Inc. Grantee Organization: Chesapeake Cares Food Pantry Jurisdiction Served: Calvert County Grant Amount: 20-021 ($100,000) Grant Project Description: Chesapeake Cares Food Pantry, the largest food pantry in Southern Maryland, will implement the Eat Smart, Move More Calvert! pilot program which seeks to serve low-income food pantry clients with diabetes and/or pre-diabetes.

CHRC grant funding will support the hiring of a Food Ambassador to develop a team of volunteer health coaches and provide for cooking classes and food distribution costs. This program will also leverage multiple health resources and community supports for participants. Multiple services pertinent to the client for achieving health and addressing other social determinants of health are provided at no cost.

Organization Contact Information: Chesapeake Cares Food Pantry Grantee Organization: Primary Care Coalition Jurisdiction Served: Prince George's County Grant and Amount: 20-022 ($140,000) Grant Project Description: Primary Care Coalition will implement the Food Is Medicine model, an evidence-based medical food and nutrition intervention to serve vulnerable, low-income food insecure patients.

The program will offer two service pathways: navigation to food assistance for individuals without a diabetes or prediabetes diagnosis; or referral to a 12-week nutrition education program with food assistance. Primary Care Coalition will use a variant of the National Diabetes Prevention Program (Stanford Protocol) which is tailored to work effectively in resource constrained settings. Clinical and biometric measures will be assessed.

The grant also supports the hiring of nine CHWs who link provider referred patients to food assistance and nutrition education. This program will implement mechanisms and tools that providers can use to ensure referrals to the Food Is Medicine program.

Organization Contact Information: Primary Care Coalition Grantee Organization : Cecil County Health Department Jurisdiction Served : Cecil County Grant and Amount : 20-023 ($275,000) Grant Project Description : The Cecil County Health Department will implement the Cecil County Diabetes Action Plan which aims to expand delivery of the evidence-based National Diabetes Plan to underserved, vulnerable low-income individuals whilst addressing common barriers to program recruitment and retention including lack of transportation and high medical expenses.

Childcare vouchers will also be distributed to parents to encourage Diabetes Prevention Month attendance. The Cecil County Health Department plans to convene their Local Health Improvement Coalition (LHIC) as the coordinating body. Organization Contact Information : http://www.

cecilcountyhealth.

org/ Grantee Organization: JHU - Rales Health Center Jurisdiction Served: Baltimore City 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: Mountain Laurel Medical Center Grant and Amount: 20-025 ($195,000) Jurisdiction Served: Garrett and Allegany Counties Grant Project Description: This program, by Mountain Laurel Medical Center at its three primary care delivery locations, will expand access to chronic care management services for patients with uncontrollable diabetes who are uninsured/underinsured, or classified as low-income, and offer free diabetes self-management education classes to improve diabetes self-management and health outcomes.

The program provides an LPN Navigator to help patients secure their diabetes medication through assistance programs, and two RNs for diabetes self-management education delivery. Organization Contact Information: http://www. mtnlaurel.

org Grantee Organization: Associated Catholic Charities - My Brother's Keeper Jurisdiction Served: Baltimore City 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: Lower Shore Clinic Jurisdiction Served: Wicomico County Grant and Amount: 20-027 ($120,000) Grant Project Description: This program by Lower Shore Clinic, a current grantee, seeks to improve access to health food for vulnerable clients with serious mental illness (SMI) who have prediabetes and diabetes by hiring a Healthy Foods coordinator to develop sustainable relationships farmers, food distribution companies and local supermarkets to obtain food that is about to expire and will otherwise be wasted.

This will improve food security, stretch food budgets and supplement SNAP. Lower Shore clients will also receive nutrition education, training on food preservation techniques and safe food storage, and opportunities to engage in physical activity. This program follows the Geisinger Health System 'Farmacy' model which has demonstrated effectiveness and is validated.

Organization Contact Information: https://www. lowershoreclinic.

org/ Grantee Organization: Anne Arundel County Department of Health Jurisdiction Served: Anne Arundel County Grant and Amount: 20-028 ($200,000) Grant Project Description: This program by the Anne Arundel County Health Department seeks to expand the capacity of the current food pantry in the county's largest food desert area, increase support for the farmer's market, and support a new, second food pantry in partnership with a community organization in Brooklyn Park.

An existing program, with funding support from the CHRC, enjoys broad support through association with community and county partners and volunteers. Improving diabetes outcomes will be achieved through better nutrition and healthier food choices, addressing obesity, and use of diabetes disease prevention and management education. Organization Contact Information: http://www.

aahealth. org/​​ Grantee Organization: Montgomery County Department of Health and Human Services Jurisdiction Served: Montgomery County Grant Amount: 20-029 ($240,000) Grant Project Description: This program by the Montgomery County DHHS proposes a multipronged approach to addressing emergency department use through better disease management among patients with Type II diabetes.

DHHS will use risk prediction to identify eligible patients. Once enrolled, patients will have access to the Chronic Care Model (CCM) and other wrap around services, including social resources to overcome social determinants of health largely delivered by CHWs. This project is highly focused on decreasing diabetes-related Emergency Department (ED) use with a target reduction of 10%.

Organization Contact Information: Montgomery County DHHS Grantee Organization: Upper Shore Aging, Inc. Jurisdiction Served: Kent County Grant and Amount: 20-030 ($90,000) Grant Project Description: Upper Shore Aging, Inc. will increase diabetes risk screening for all low-income seniors served by Upper Shore Aging, including those attending senior centers and home-bound seniors.

Home screenings will be performed in partnership with Meals on Wheels. The program seeks to increase awareness of diabetes risk factors and provide risk prevention education and increase food security by improving access to healthy fruits and vegetables delivered with Meals on Wheels home meals.

The program will seek increased collaboration among health care providers and will work with the Kent County Health Department and Kent County Department of Social Services to increase no cost access to Diabetes Prevention Programs for Medicare recipients.

Organization Contact Information: Upper Shore Aging Grantee Organization: Baltimore Medical System Jurisdiction Served: Baltimore City 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: Worcester County Health Department Grant and Amount: 19-021 ($225,000) Jurisdiction Served: Worcester County Grant Project Description: This project would address obesity prevalence among youth and adults in the jurisdiction through a number of intervention strategies that include online education learning modules; coaching and wearable technology; community gardening projects; linkages with local food pantries; and virtual and in-person cooking demonstrations and grocery store tours.

Program referrals would come from the Health Department and Chesapeake Health Care. The overall goals of the project are to promote healthier lifestyle choices (both exercise and nutrition) among the target population, weight loss, weight management, and improved food security. Organization Contact Information: www.

worcesterhealth. org​​ Grantee Organization: Washington County Health Department Grant and Amount: 19-022 ($135,000) Jurisdiction Served: Washington County Grant Project Description: This project would support the use of a mobile farmer's market to get locally grown fresh fruits and vegetables into the city of Hagerstown where there is no supermarket.

The project targets vulnerable populations, and the vendor would sell the produce at Title I schools, low-income housing sites, Commission on Aging, congregate meal sites, and the senior center. The mobile farmer's market would accept food stamps/EBT, WIC vouchers, and cash. In addition, the project involves providing nutritional education, to be provided by Meritus Medical Center, the Health Department, and a local dietician.

Organization Contact Information: https://washcohealth.

org/ ​​ Grantee Organization: Somerset Health Department Grant and Amount: 19-023 ($300,000) Jurisdiction Served: Somerset County Grant Project Description: This project would implement the Sustainable Change and Lifestyle Enhancement (SCALE) for Families project, a comprehensive weight loss and health improvement plan for low-income and uninsured adults, modeled after an evidenced-based program in West Virginia.

The project would target population of