Target Population: 

Older Adults and people with disabilities, 

diverse consumers, hard-to-reach minorities 

 

 

 

 

 

 

Scaling Network Lead Entities Grantee Profile 

Network Name: MAC Incorporated 

Grant Goal: 

MAC Inc. will serve as a Network Lead Entity (NLE) in making the linkages between clinical and community-based services to 

improve the lives of Marylanders. The goal is to standardize social determinants of health (SDoH) screenings across the aging 

network, including nonprofit community organizations, primary care providers and hospitals, and align these services for referrals 

and reimbursement through Maryland’s Total Cost of Care Model (TCoC). 

Grant Partners: 

• Maryland Department of Aging 

• MD Department of Health 

• Chesapeake Regional Information System for Patients (CRISP) 

• Johns Hopkins School of Medicine Division of Geriatric Medicine 

and Gerontology 

• Frederick Health 

• Tidal Health 

• Anne Arundel County Department on Aging 

• Cecil County Department of Community Services 

• Queen Anne’s County Department of Community Services 

• The Prince Georges County Department of Family Services 

• Upper Shore Aging, Inc. 

• Washington County Commission on Aging, Inc. 

• Asian American Center of Frederick 

• Asian Indians for Community Service, Inc. (AICS) 

• Chinese Culture and Community Service, Inc. 

• Esperanza Center 

• Keswick Multicare Center 

Award: 

$291,223 

Grant Objectives: 

1) Strengthen pathways for referrals to screen and track older 

adults and individuals with disabilities for risk of food insecurity, 

social isolation, and/or benefit from referral to evidence-based 

self-management and falls programs 

2) Encourage physicians and hospitals with patients who could 

benefit from these services to connect with community 

providers 

3) Collaborate with the Center service providers to track changes in 

health status and healthcare cost reduction via CRISP 

4) Work to increase data-sharing of outcomes across clinical, 

nonclinical system through CRISP. 

Grant Contact: 

Grant Summary: 

MAC Inc. plans to use this grant to continue to 

coordinate activities with efforts already underway by 

the MD Department of Aging State Plan to develop 

integrated statewide systems to support access to and 

sustainability for billing. Their efforts will promote a 

continuum of care between clinical and community 

providers to holistically address SDoH needs and use 

CRISP to show return on investment and bidirectional 

data sharing. 

The Maryland Living Well Center of Excellence (LWCE) 

previously began piloting SDoH screening in conjunction 

with evidence-based programs (EBPs). Individuals with 

SDoH needs are referred to Maryland Access Point 

entities, the state’s No Wrong Door System, Information 

and Referral System via Area Agencies on Aging (AAAs) 

to match them with services. This grant will allow them 

to continue to integrate a stateawide system to support 

access, sustainability of, and participation in EBPs, 

implement standard screening for SDoH needs, establish 

a multi-cultural aging network, work with 3 MD hospitlas 

and the MD Primary Car Program to document ROI and 

improved quality of life, and leverage existing contracts 

and transition to direct reimbursement models to lead 

to sustainable funding streams. MAC Inc. understands 

that creating policy and practice opportunities that are 

the first steps toward sustainability beyond the funding 

period. With MDoA, LWCE will coordinate strategic 

planning and oversee network performance across 

organizations through the Network Reimbursement 

Learning Collaborative. Together work will be done with 

the AAAS and nonprofits to implement a system of 

accountability and quality improvement at all levels. 

Planned Activities for NLE enhancement will focus on: 

☒Leadership 

☒Finance 

☒Business Development 

☒Network Development and Support 

☒Network Administration 

Leigh Ann Eagle, Executive Director Living Well Center of Excellence, laeagle@macinc.org