Public Health and Grants Offices Co-Managing Settlement Dollars
A City-Led, Data-Anchored Model for Managing Opioid Settlement Funds
Baltimore pursued its own litigation and built a two-office city administration that pairs public health strategy with grants management expertise, funds 22 named partners and a competitive community grant round guided by a community advisory board and publishes every dollar on a public dashboard.
The Challenge They Were Addressing
Through 2024, Baltimore consistently experienced some of the highest overdose numbers in Maryland. In 2024, when the city received this funding, Baltimore also had one of the highest overdose rates among similarly sized cities nationwide. When negotiations for the national opioid settlements entered a phase requiring local jurisdictions to sign on, the city's legal team and the mayor assessed Baltimore's share under the global agreements. They compared it with the scale of the local crisis. The share paled next to the need. The city declined the global settlements and continued its own suits against opioid manufacturers and distributors, which produced a distinct restitution fund flowing directly to Baltimore.
That decision created a governance problem the city had to solve on its own. A restitution fund with negotiated earmarks for 22 named organizations totaling $87 million, plus additional settlement dollars, needed a way to move through the city with transparency, accountability, and a public health strategy. There was no template. Peer cities were signing onto the global settlements and receiving allocations through state processes. Baltimore had to build the administrative machinery from scratch.
The city also had a running head start. The Mayor's Office of Recovery Programs (MORP) had already administered $641 million in American Rescue Plan Act funds and reached 99.7% expenditure. MORP had grant agreement templates, risk assessment protocols, payment processes, and lessons learned about what to avoid the next time. What MORP did not have was deep public health expertise in overdose response. The city's answer was to establish a second office, BCMOOR, in August 2024 by executive order and pair the two.
What They Built
Baltimore built a two-office administrative model. BCMOOR sets the strategy, holds relationships with grantees, and connects the fund to public health evidence. MORP builds and monitors grant agreements, oversees finances, and runs the systems that already manage the city's federal recovery dollars.
The fund itself moves through three streams. 22 named earmarks totaling $87 million flow to specific organizations named in the settlement agreements. Each named grantee submits an application defining scope, budget, and work plan, and the two offices work with the applicant to align the scope to the city's overdose response strategic plan. A separate competitive stream, the community grants, opens each fiscal year with priorities set by the Restitution Advisory Board. A third stream funds city agency work directly, including the fire department's Population Health Team, homeless services, and the health department.
The Restitution Advisory Board is the community anchor. Its members carry lived and professional experience with the overdose crisis, meet regularly, and set annual fiscal priorities that shape the competitive request for proposals. The board is engaged in decisions rather than briefed on them after the fact, and Sara Whaley's team spends significant time building those relationships and identifying opportunities throughout the process for the board to weigh in on.
Grantees also receive active support. In addition to monthly office hours, both offices run Link and Learns, a quarterly convening that brings funded organizations together to network, share problems, and discover what their peers are doing. Monthly workshops, quarterly Link and Learns, and monthly office hours cover specific topics such as hiring and supporting peer staff, serving older adults, or building data collection practices that connect a program's activities to its outcomes. BCMOOR staff work with grantees on capacity questions that the grant is not built to solve. The strategic goal is sustainability. Every partner should be stronger and more competitive for the next grant by the time the restitution funding runs out.
A public dashboard rounds out the model. It lists every funded organization, the approved use under the executive order, the dollar amount, and a description of the work. Baltimore publishes the dashboard to show residents, funders, and peer jurisdictions how restitution dollars are being spent and to hold the city to its own standards.
Who You Need at the Table
What made a willing partner essential vs. optional?
Four of the partners share one trait: each holds a piece of the administrative model that no one else in the city could deliver. The Law Department pursued the independent suits that created the fund. MORP brought a grants management infrastructure built through ARPA. BCMOOR brought public health strategy and grantee relationships. The Restitution Advisory Board brought community authority and living and lived experience.
The 22 named grantees are also important, but for a different reason. They are named in the settlement agreements themselves. The city negotiates a scope of work with each one that aligns with the strategic plan, then supports that organization's capacity throughout the life of the grant. Helpful partners, including peer state administrators and external research groups, extend reach and shared learning but are not on the critical path for grant execution.
Budget Breakdown
What is the minimum viable budget to replicate this?
Depending on the volume of grants, the minimum viable version of this model needs three positions in place before the first grant closes. One strategy lead is responsible for the public health direction and the grantee relationships. One grants manager is responsible for the legal and financial monitoring. One project manager works across both. A jurisdiction with an existing federal grants office or ARPA office can house the grants function inside that team, as Baltimore did with MORP, rather than standing up a parallel structure. What must not be cut is the pairing. A strategy lead without a grants function will move slowly and stumble on documentation. A grant-making function without a strategy lead will move quickly and lose the connection to public health outcomes.
What Worked and Why
Specific decisions or design features that drove success
Pairing a public health office with a grants management office produced faster grant agreements and stronger scopes than either office could have delivered alone. MORP brought templates, risk assessment protocols, and payment infrastructure from ARPA. BCMOOR brought the public health strategic plan, evidence-based practice knowledge, and the grantee relationships needed to shape each scope. The paired project managers meet weekly on each grant and share the same working documents. The setup meant Baltimore did not have to build grant infrastructure from scratch.
Anchoring every funding decision in a needs assessment and strategic plan gave the city a defensible answer to every naysayer. Baltimore conducted a citywide overdose needs assessment, developed a strategic plan including community feedback, and required every funded scope of work to tie back to it. When constituents challenge a specific allocation, the city can point to the data. The team calls this rooting decisions in evidence rather than in personal preference, and it takes the pressure off individual staff members to justify every trade-off in isolation.
Baltimore established the Restitution Advisory Board as an active decision-making partner, and that is where the community grant round derives its legitimacy. Board members set the annual competitive priorities, are consulted before major shifts, and receive follow-up on the feedback they provide. Baltimore has treated the board as a decision-making partner in the community grant strategy, which is why the annual RFPs are credible.
Funding the capacity of existing organizations moved dollars faster and produced outcomes sooner than launching new and untested models would have. Baltimore already had a strong nonprofit infrastructure. Rather than invent programs, the city expanded existing ones. Healthcare for the Homeless and the Behavioral Health Leadership Institute both had mobile teams and street medicine capacity before the restitution funding. Community grant dollars extended their hours, added service locations, and covered finance staff costs, so smaller organizations could properly manage the grant. This choice was described in the interview as less sexy than launching something new, and Sara Whaley named it the design decision she is most confident about.
The dashboard signals to the public that the city takes the investment seriously, and it gives grantees a shared reference point. The dashboard lists every funded organization, the approved use under the executive order, the dollar amount, and a short description. It also works as an internal alignment tool. Grantees can see the full portfolio, spot potential collaborators, and understand how their work fits into the citywide strategy.
Monthly monitoring works differently when the office invests in the grantee relationship instead of policing it. MORP reviews receipts, payroll, and expenditures against the approved budget every month. That cadence is deliberately supportive. It lets the team step in early when a grantee is drifting, before a quarterly review would surface the problem too late to fix. BCMOOR's first step in addressing any grantee difficulty is to ask how the office can help resolve it. That posture, described in the interview as high standards paired with high support, is what turns a monthly financial review into technical assistance rather than a gotcha exercise.
Early outcomes and data
Approximately $124 million from March 2025 to June 2026 was allocated across named grantees, competitive community grantees, and city agency programs (data as of June 30, 2026).
22 named partner organizations funded through negotiated earmarks totaling $87 million.
Competitive community grant round completed with priorities set by the Restitution Advisory Board and awards issued for low-barrier mobile treatment services and other community-identified needs.
Public dashboard live at baltopi.shinyapps.io/ORF-dashboard/ listing every funded organization, dollar amount, and approved use.
Monthly financial oversight in place for every grantee; standard measure set adopted for outcome reporting aligned with the citywide strategic plan.
The Restitution Advisory Board delivered a keynote at the National Opioid Settlement Conference in Denver, and the program director presented there on outcome measurement.
Statewide peer-learning group of Maryland opioid settlement administrators established; contract templates and process resources exchanged across jurisdictions.
Lessons Learned
Pair public health expertise with grants management from day one. Neither office can carry the model alone. Baltimore's decision to house grants administration within MORP, which had already administered $641 million in ARPA funds, allowed BCMOOR to focus on strategy and grantee relationships. Pairing shortens ramp time and produces stronger grant agreements.
Root every funding decision in data and a strategic plan. A needs assessment and a written strategic plan turn every allocation question into a reference to shared evidence. This is the shield against naysayers, the framework for the advisory board, and the reason grantees know why they are being funded.
Build capacity in existing organizations before launching new ones. Baltimore invested in the capacity of organizations that had been doing this work for years, expanding their hours, adding service locations, and hiring finance staff. Sustainability comes from stronger existing partners who can compete for other grants once restitution dollars run out.
Convene grantees to meet each other. These convenings break down silos, surface partnerships, and reduce the pressure any single organization feels to be everything to everyone. A grantee described the first Link and Learn as the moment their organization realized it did not have to carry the whole city on its own.
Publish the dashboard early. Transparency about who is funded, for what, and for how much conveys to the public that the city takes the investment seriously. It also aligns grantees around the shared portfolio.
Spend time on the advisory board relationship. A board is only as useful as the trust between its members and the settlement office. Baltimore's Restitution Advisory Board is credible because the team spends time on the relationship, is thoughtful about what the board is asked to weigh in on and follows up on feedback.