Evidence-Based Community Health Programs
Six interconnected programs that build lasting public health infrastructure, train community leaders, generate actionable data, and deliver direct health services to Baltimore's most underserved neighborhoods.
Community Health Worker Training Academy
Our flagship 16-week Community Health Worker (CHW) certification program is the most comprehensive CHW training available in the state of Maryland. Designed in partnership with Johns Hopkins Bloomberg School of Public Health and approved by the Maryland Department of Health and Mental Hygiene, the curriculum prepares community members to serve as trusted health navigators, patient advocates, and chronic disease management coaches in their own neighborhoods.
The Academy combines rigorous classroom instruction with extensive supervised practicum experience in partner health systems, Federally Qualified Health Centers, and community-based organizations across Baltimore City. Each cohort enrolls 24 participants, with priority given to residents of medically underserved ZIP codes who demonstrate strong community ties and a commitment to health equity.
Core Curriculum Modules
- Social Determinants of Health & Health Equity Frameworks
- Chronic Disease Management: Diabetes, Hypertension, Asthma, Obesity
- Motivational Interviewing & Trauma-Informed Communication
- Health Insurance Navigation & Benefits Enrollment
- Community Health Assessment & Participatory Research Methods
- Mental Health First Aid Certification (8-hour MHFA course)
- Cultural Competency & Language Access Best Practices
- Electronic Health Record Documentation & Care Coordination
Program At a Glance
Next Cohort: Spring 2027
Applications are now open for Cohort 19. Priority deadline: February 14, 2027. Rolling admissions through March 1.
Apply Now →Neighborhood Health Needs Assessment
Our Neighborhood Health Needs Assessment (NHNA) program conducts rigorous, community-participatory health assessments in underserved Baltimore neighborhoods. Each assessment produces a comprehensive health profile that includes household-level survey data, qualitative findings from focus groups and key informant interviews, GIS-mapped health resource inventories, and environmental hazard analyses.
Our assessment methodology was developed in collaboration with the Johns Hopkins Center for Health Equity and has been peer-reviewed and published in the American Journal of Public Health. The methodology has since been adopted by the Maryland Department of Health, the Virginia Department of Health, and the District of Columbia Department of Health for their tri-annual Community Health Improvement Planning (CHIP) cycles. Each assessment involves training and deploying 15 to 20 community data collectors who conduct door-to-door surveys in partnership with local block captains, faith leaders, and community association presidents to ensure representative sampling and high response rates.
Assessment Components
- Household health status surveys (validated, 45-item instrument)
- Community focus groups (6-8 per neighborhood)
- Key informant interviews with local providers
- GIS health resource mapping within 1-mile radius
- Environmental hazard proximity analysis
- Social Vulnerability Index scoring
Deliverables
- 200+ page comprehensive needs assessment report
- Executive summary for policymakers
- Interactive data dashboard (open-source)
- Community presentation materials
- Priority health improvement recommendations
- Grant-ready data packages for funders
Completed Assessments
- East Baltimore (2014, 2017, 2020, 2023)
- Cherry Hill / Brooklyn (2015, 2019, 2022)
- Park Heights / Pimlico (2016, 2020, 2024)
- Sandtown-Winchester (2017, 2021)
- Curtis Bay / Hawkins Point (2018, 2022)
- Belair-Edison / Clifton Park (2019, 2024)
Mobile Clinic Development
Our Mobile Clinic Development program provides end-to-end technical assistance for launching and sustaining mobile health units in medically underserved areas (MUAs). From vehicle procurement and clinical equipment specifications to staffing models, billing infrastructure, and route optimization, our team guides partner organizations through every phase of mobile clinic implementation.
Currently, CC Health Dev operates three mobile health units serving 14 neighborhoods across Baltimore City and Baltimore County. Each unit is staffed by a licensed nurse practitioner, a medical assistant, and two certified Community Health Workers. Services include primary care screenings, chronic disease monitoring (A1C, blood pressure, lipid panels), immunizations, social determinants screenings using the PRAPARE tool, and warm referrals to specialty care. In fiscal year 2025, our mobile units completed 18,742 patient encounters, with 67% of patients reporting no other regular source of primary care. Our route optimization model, developed with Morgan State University's Transportation Engineering program, ensures each unit serves the highest-need census tracts with the least transportation-accessible fixed-site clinics.
Health Equity Data Dashboard
The CC Health Dev Health Equity Data Dashboard is an open-source, real-time data visualization platform that aggregates ZIP-code-level health indicators across Baltimore City. The dashboard integrates data from the Maryland Health Services Cost Review Commission, Baltimore City Health Department vital statistics, the U.S. Census American Community Survey, and our own Neighborhood Health Needs Assessment surveys to provide a comprehensive, continuously updated picture of health equity conditions at the neighborhood level.
Key indicators tracked include emergency department utilization rates, chronic disease prevalence (diabetes, hypertension, asthma, COPD), food access scores (USDA Food Access Research Atlas), environmental hazard proximity (EPA EJSCREEN), social vulnerability indices (CDC SVI), and maternal and infant health outcomes. The dashboard is used by three Baltimore-area health departments, twelve community-based organizations, and the Johns Hopkins Center for Health Equity for population health management, grant writing, and resource allocation decisions. The platform is built on open-source technologies and all underlying data is available via API for researchers and community organizations.
Youth Public Health Pipeline
The Youth Public Health Pipeline is a six-week summer immersion program for Baltimore City public high school juniors and seniors exploring careers in public health, epidemiology, community medicine, and health policy. Developed in partnership with Morgan State University School of Community Health and Policy and the Johns Hopkins Bloomberg School of Public Health, the program provides students with hands-on exposure to public health research methods, community health assessment fieldwork, and career mentorship from practicing public health professionals.
Each cohort of 20 students completes a mentored community health research project, shadows certified Community Health Workers in the field, tours public health laboratories and health department operations centers, and receives individualized college application support for health sciences programs. Since its inception in 2016, the Pipeline has served 178 students, with 89% enrolling in post-secondary health sciences programs and 34% pursuing graduate degrees in public health or related fields. The program is fully funded through a combination of HRSA pipeline grants, institutional partnerships, and private philanthropy, with no cost to participating students or families.
Clinic Capacity Building
Our Clinic Capacity Building program provides consulting and implementation support for Federally Qualified Health Centers (FQHCs), community health centers, and hospital-based outpatient clinics seeking to integrate Community Health Workers into their care teams, implement standardized social determinants of health screening, establish quality metrics dashboards, and develop sustainable third-party billing frameworks for CHW services.
Since 2018, we have partnered with 23 clinical sites across Maryland and the District of Columbia. Our technical assistance includes workflow redesign for CHW integration into primary care teams, training clinical staff on collaborative care models, implementing validated SDOH screening tools (PRAPARE, AHC-HRSN), establishing Medicaid managed care organization billing pathways for CHW services, and developing quality improvement dashboards that track both clinical outcomes and patient-reported experience measures. Partner sites that complete our 12-month capacity building program report an average 31% reduction in emergency department utilization among CHW-enrolled patients and a 22% improvement in chronic disease management metrics.