Shown at the MRHA Awards presentation are Lara Wilson, Director of Rural Health Care Transformation at UM Shore Regional Health; UM Shore Medical Center at Chestertown SCOT team members Michele Matthews, Amanda Webster ,Emily Welsh and Serenity Kelly; and Zack Royston, Vice President, Rural Health Care Transformation at UM Shore Regional Health and Executive Director, UM Shore Medical Center at Chestertown.

The University of Maryland Shore Medical Center at Chestertown’s Shore Community Outreach Team (SCOT) is being honored by the Maryland Rural Health Association (MRHA) as recipients of its 2024 Outstanding Rural Health Program Award.

SCOT team members Emily Welsh, MSN, RN, Nurse Coordinator, Social Worker Michelle Matthews, LCSW, and community health advocates Serenity Kelly, CCHW, and Amanda Webster, CCHW, received the award at MRHA’s annual awards ceremony.

Nominated by Lara Wilson, Director of Rural Health Care Transformation at University of Maryland Shore Regional Health (UM SRH), the outreach team was selected for the award based on their outstanding work in providing effective, community-oriented rural health care delivery and excelling in their service to rural communities. UM SRH is a member organization of the University of Maryland Medical System (UMMS).

Focusing on the underserved and vulnerable populations in Kent and northern Queen Anne’s counties, the mission of SCOT is to improve the community’s health by collaborating with local partners to bring health care access and support services to residents in their homes and community settings. In Fiscal Year 2024, SCOT served 90 people through community case management, provided a total of 304 health blood pressure and diabetes (A1c) screenings at sites throughout Kent and northern Queen Anne’s counties, conducted 679 home visits and connected dozens of patients to primary care, mental health services and medication reconciliation support.

“I am continually blown away by the reach this team has achieved within our communities and the incredible impact they are making for our residents,” said Wilson, who was on hand to present the award. “They are an amazing resource for our vulnerable populations, and their ongoing collaboration with local government entities, nonprofit and civic groups promises to advance their reach even further.”

SCOT also developed a number of creative initiatives to assist local residents in need of support services. These include a raised gardens program, block parties at senior communities and the African-American Health Advisory Committee, which they helped launch to offer health education events geared to the concerns of the local Black community.

“I am very fortunate to have such a dedicated and passionate team,” Welsh said in accepting the award on behalf of the SCOT members. “This award motivates us to continue our vision to be a leader in excellent patient care and the transformation access to health care in rural communities. We will use this recognition to strengthen our program further, expand our reach and improve the health and well-being of even more people.”

Kent County Shore Community Outreach Team members Michelle Matthews, Emily Welsh and Amanda Webster are shown with their patient, William Miller, whom they helped to overcome homelessness while supporting his recovery from various health problems.

Modern day health care is complicated. Most diagnoses and treatments come with a long to-do list for each patient—appointments, prescriptions, co-pays, physicals, bloodwork, follow-ups, paperwork.

Now imagine attempting all of that as an elderly person without access to a computer, or as someone who lives in a rural area with little or no family support, and without a car or a phone. Health issues are much more difficult to manage for individuals and families facing these circumstances, and — as William Miller, a retired veteran from Chestertown discovered after a fire destroyed his home — even more so for someone who is unhoused.

Miller is a familiar face in Chestertown—he worked for several years as the janitor at Chestertown Middle School. His 13 years of service in the National Guard included work as a cook, a skill he later put to good use at the former Old Wharf restaurant, where he was proud to prepare their crab bisque, a local favorite.

Even before the fire, Miller experienced serious health issues. After, he struggled to find a permanent place to live, staying for long periods in motels. “I’d been ill for a long while and in the hospital many times,” he said. “I had seizures, then surgery on the brain. I had a pacemaker put in. Once out of the hospital, I needed help to keep recovering.”

Fortunately for Miller and other folks experiencing health issues and personal hardship, University of Maryland Shore Regional Health (UM SRH), a member organization of the University of Maryland Medical System, offers Shore Community Outreach Teams (SCOT)  in both Kent and Dorchester counties. Serving patients in home and community settings, SCOT helps patients overcome barriers to health care.

The Kent County SCOT team includes Nurse Coordinator Emily Welsh, MSN, RN, Social Worker Michelle Matthews, LCSW-C and Community Health Advocates Serenity Kelly, CCHW, and Amanda Webster, CCHW. The team provides medical case management and conducts outreach events that include free screenings for conditions like high blood pressure and diabetes. By finding physicians and making appointments, connecting with resources through community partners, and securing transportation, meals, housing or phones, the team provides comprehensive support for patients navigating health challenges. Patients’ limited finances are not an obstacle—SCOT’s services are provided free of charge.

Patients may be referred to SCOT by their health care providers, family members, neighbors or friends, and they may also self-refer. Then SCOT swings into action, visiting the individual to conduct an assessment that includes medications and health needs as well as information about his or her support network and resources. With the patient’s input, they create an individual plan to help overcome barriers to care.

“Our patients face health disparities like not having access to food, not being able to afford utilities, lack of transportation, not having health insurance, not understanding information they’re getting from their doctor and even not having a primary care doctor,” said Matthews. “And of course, not having a home is a huge disparity. The health care system is complex, and for someone who doesn’t have stability, navigating it is even harder.”

Although SCOT wasn’t created specifically to address homelessness, recently the team has worked with Miller and three other community members who needed housing. All four have been successfully rehomed.

“These individuals weren’t referred because they were homeless — it was something we learned while working with them,” Matthews said. “If your basic needs aren’t being met, you’re not focused on getting to your doctor, doing preventive health screenings or maybe even keeping up with your medications, especially if you don’t have access to the internet or a smartphone. While following up on issues like their needing a doctor and problems accessing medication, we saw that their lack of housing was something we needed to help them resolve.”

Today, with its needlework pillows and family photos, Miller enjoys a cozy and comfortable home, thanks in no small measure to SCOT’s collaboration with other local organizations. Working with Upper Shore Aging, the team applied for senior housing and energy assistance on Miller’s behalf. They coordinated with Social Services for help in funding his first month’s rent and with Tides of Grace, a Stevensville nonprofit, for help furnishing Miller’s new apartment in Centreville. The team also contacted County Ride to ensure Miller had transportation, and arranged for his prescriptions to be transferred to a Centreville pharmacy and for home meal delivery to come from a local service.

In the case of another patient the team helped to rehome, Father Henry Sabetti at Kent County Coalition for the Homeless was an active partner. “Collaboration with community partners is critical to our success in getting patients the full complement of help they need to manage their health challenges and achieve a better quality of life,” said Welsh. “It’s a team effort that includes a wide network of key staff members in health and social services departments and in local organizations.”

When Miller’s apartment was ready for occupancy, members of SCOT moved him in and got him settled. “I love it right here, I’m so glad they got it,” Miller said of his home. “Michelle, Amanda and Emily helped me out. I had been ill and they got me help from home care workers after a couple of my surgeries. Since then, they’ve been with me quite a while.”

Team members continue to check in on Miller via phone – Welsh monitors his medication, Matthews keeps up with his VA transportation and paperwork, and Webster makes contact to be sure he remains safe and comfortable. This kind of above-and-beyond patient care is the norm for SCOT members, who smooth the way forward for patients to achieve their best quality of life and a foundational standard of health care.

“It’s rewarding to see a situation improve for someone—and to know that we are filling a void where otherwise, there wouldn’t be support,” said Matthews. “Our team is small but mighty, and when everything comes together, we see the difference we’re making and that’s a good feeling.”