<![CDATA[Primary Care Coalition - News]]>Wed, 01 Jul 2026 23:28:47 -0400Weebly<![CDATA[Finding the Human Story in the Data: Rafael Ramirez’s Work at PCC]]>Tue, 30 Jun 2026 16:17:54 GMThttps://www.primarycarecoalition.org/news/finding-the-human-story-in-the-data-rafael-ramirezs-work-at-pccFor Rafael Ramirez, data has never been just numbers on a spreadsheet. As a Senior Data Analyst with the Primary Care Coalition’s (PCC) Population Health team, Rafael helps support the Care for Kids Program and Nexus Montgomery Regional Partnership, a collaboration of Montgomery County’s six hospitals for which PCC provides infrastructure and operations support. His work helps teams ask better questions, understand community needs more clearly, and improve the way care is delivered.  Rafael’s story is a reminder that behind every data point is a person, a family, and a community. And for Rafael, that human connection is what makes the work meaningful.   

That connection between numbers and people has been part of Rafael’s life for as long as he can remember.  “As a child growing up in Mexico, I was always intrigued by data and statistics,” Rafael says. “But not just for the math reasons. I wanted to see how they connected to people and their lives.” 

Before joining PCC 12 years ago, Rafael worked as a data analyst in the healthcare group at the World Bank, where his understanding of data’s human impact continued to grow. Over time, he began to see the numbers not just as information, but as a way to better understand people’s experiences and improve their lives. “During my time at the World Bank, I began to understand the links between the numbers and statistics I was looking at and their real-world impact,” Rafael says. “That desire to do work that had an impact on people is what led me to PCC.” 

His introduction to PCC felt different from the start. Rafael interviewed with Dr. Tom Lewis, Fareed Anjum, and Charity Dorazio, who at the time made up much of PCC’s IT department. “It was more of a conversation than a traditional interview, which I found very appealing,” he recalls. 

Once he joined the organization, Rafael quickly understood why that conversation had felt so natural. “We at PCC are very collaborative,” he says. “Given that we all come from different backgrounds and skill sets, this seemed to me like the right place to do the type of work I like to do.” 

That collaborative spirit—and Rafael’s thoughtful, almost visionary approach to data analysis—has made a lasting difference. In 2017, he was named an Employee of the Year by the Healthcare Council of the National Capital Area, an honor given annually to employees of member organizations who have made extraordinary and sustainable contributions in the prior year.  “Rafael has been instrumental in supporting the data and analytical needs of Nexus,” says Mindy Pierce, PCC Senior Director, Population Health,  “Nexus is a unique partnership focused on coordinating community resources to improve overall health of the community while reducing hospital and total health care costs.  And Rafael’s work makes it possible for us, as a program, to have the impact we are having.” 

But there is much more to Rafael than data. Away from work, one of his great passions is soccer, especially Mexico’s national team, El Tri. 

“I played myself and love the game, but I knew that my career path wasn’t with the ball on my foot,” Rafael says with a laugh. Even as a fan, though, his analytical side comes through. “Soccer is a beautiful, fluid game, but there are numbers there that can tell you a lot about a team. I love digging into them so I can better appreciate what I’m seeing.” 
With the World Cup underway, Rafael is hoping El Tri will continue to succeed. Still, even though he is a “people person” and loves celebrating with friends and fellow fans, he admits he prefers to watch the games on his own. “I get so into it,” he laughs. “I think it is better for everyone if I watch on my own.” 
​
Rafael also finds steady support in his family. He lives in Kensington, MD with his wife of 20 years, their daughter, and two guinea pigs, Spots and Moon. Family is woven through the things he cares about most, offering both comfort and perspective. “It’s easy to get caught up in what I do,” Rafael says. “They help keep me grounded and connected to what matters most: people. And in many ways, that is at the heart of what PCC and I are trying to do every day.” ]]><![CDATA[Building a Behavioral Health Workforce Pipeline Through Supervision]]>Tue, 30 Jun 2026 03:07:50 GMThttps://www.primarycarecoalition.org/news/building-a-behavioral-health-workforce-pipeline-through-supervisionBecause nearly 80% of Montgomery Cares patients speak Spanish, the job descriptions for Montgomery Cares Behavioral Health Program positions include a requirement that staff be bilingual in English and Spanish. It’s one way the Primary Care Coalition (PCC) takes seriously our commitment to providing culturally and linguistically appropriate care.* But finding the licensed mental health professionals—or registered nurses with behavioral health experience—to fill these roles is hard. 

A 2024 state-commissioned report on the behavioral health workforce, projected Maryland needs more than 12,000 new counselors and clinical social workers by 2028. It noted that Latino behavioral health professionals are in particularly short supply, with less than 5% of behavioral health professionals identifying as Latino versus nearly 12% of Maryland residents. Reported proportions are even more stark in Montgomery County, where 21% of residents identify as Latino but only 10% of behavioral health workers do. Of course, not all bilingual workers identify as Latino, but Psychology Today’s therapist directory lists only 353 therapists operating in Montgomery County after filtering for Spanish-speaking professionals. That’s roughly 12% of the more than 3,000 therapists the platform counts serving the county overall.  

“Recruiting the behavioral health staff our patients need is hard,” says Sarah Frazell, Director of Behavioral Health at PCC. “There simply aren’t enough Spanish-speaking providers in the area, and PCC is competing with hospitals, county government, or private practice platforms and businesses.  We’ve always had to be creative about recruitment.” 
To address that challenge, MCBHP has built a pipeline approach to hiring by supervising recent graduates who have completed a master’s degree in social work. In Maryland, these graduates must first pass the master’s-level licensing exam to become licensed master social workers before they can begin counting the supervised clinical experience required for the licensed certified social worker-clinical credential (LCSW-C). To progress from LMSW to LCSW-C, they must complete at least two years and 3,000 hours of supervised clinical social work experience, including substantial face-to-face client contact and documented weekly clinical supervision by a qualified LCSW-C supervisor, then pass a clinical licensing exam. 

For developing clinicians, that supervision is essential. Full licensure allows social workers to independently diagnose and practice without clinical supervision, but getting there requires access to both practice hours and qualified supervisors. PCC’s current behavioral health team includes several clinical social work supervisors, allowing PCC to offer both. In prior years, PCC was also able to offer a similar model for graduate-level mental health counselors through a partner health center, but that partner no longer has counseling supervisors on staff. Without in-house clinical supervision capacity, professionals in training often have to pay for outside supervision, which can be cost prohibitive. 
The model of providing in-house supervision for new graduates benefits PCC as well as the clinicians it supports. Graduate-level staff gain the clinical practice they need while getting to know the Primary Care Coalition and the day-to-day experience of working in the safety net. Many find it a good fit and continue with PCC after completing their supervised hours. Even so, natural turnover can still create long vacancies on the behavioral health team, prompting current supervisors to look for additional ways to attract and support developing professionals. 

Additionally, PCC is reintroducing its internship program to strengthen the pipeline of social work interns. Since PCC first began partnering with interns in 2014, the organization has hired seven former interns as behavioral health care managers. Over the years, PCC has worked with programs including UMBC at The Universities at Shady Grove and the University of Maryland School of Social Work, and is currently exploring a new partnership with Trinity University. Two social work interns are expected to join the team for the upcoming school year. 

One next step is expanding that supervisory capacity beyond social work. PCC’s Director of Behavioral Health and two other care managers—all clinical social workers—have begun the application process and an 18-credit training program that will allow them to support licensed graduate professional counselors (LGPCs). Once credentialing is complete, they will be able to supervise half of the hours required for LGPCs to become fully licensed clinical professional counselors (LCPCs).  
​
For emerging bilingual clinicians, opportunity is growing at PCC—not just for a job or practicum, but for mentorship, meaningful clinical experience, and a pathway to long-term impact in the community. 

*Some partner health centers provide integrated behavioral health care with their own staffing, which allows coverage for other language needs. For example, the CCACC Pan-Asian Volunteer Health Center offers counseling in Mandarin.

]]><![CDATA[Montgomery Cares Strengthens Diabetes Care, With Opportunities to Expand Specialty Access]]>Tue, 30 Jun 2026 03:03:11 GMThttps://www.primarycarecoalition.org/news/montgomery-cares-strengthens-diabetes-care-with-opportunities-to-expand-specialty-accessAs communities recognize Diabetes Week, Montgomery Cares continues to make meaningful progress in supporting patients with diabetes, according to the latest network performance data. In FY24, approximately 20% of Montgomery Cares patients had a diabetes diagnosis—nearly double the statewide incidence in Maryland—making diabetes prevention, monitoring, and treatment a critical priority for the program. 

One of the network’s strongest areas is HbA1c testing, a key measure used to monitor blood sugar levels over time. After tracking close to the HEDIS Medicaid HMO average for several years, Montgomery Cares surpassed the HEDIS benchmark in FY22 and continued improving, reaching a 90% testing rate in FY24. Regular HbA1c testing helps providers identify whether patients are maintaining healthy blood sugar levels and allows care teams to intervene before complications develop. 

Blood sugar control has also improved since the pandemic. The share of patients with controlled blood sugar increased from 51% to 57%, reflecting steady recovery and renewed engagement in care. At the same time, the data point to continued need: 31% of Montgomery Cares patients with diabetes have uncontrolled blood sugar, compared with the HEDIS Medicaid HMO average of 35.8%. While the network is outperforming that benchmark—a lower score is better, in this case—roughly one in three diabetic patients remains at increased risk for serious complications, including kidney disease, vision loss, nerve damage, amputations, heart attack, and stroke. 

The report highlights several strategies that could help build on this progress. Expanding food-as-medicine programs would provide patients with greater access to healthy foods that support blood sugar control. Integrating nutrition support into chronic condition case management—alongside nursing support—could also help patients stay engaged in care and better manage diabetes and related conditions such as hypertension. 

Specialty care access remains another important opportunity. Diabetic retinal exam rates rose from 19% in FY23 to 29% in FY24, but this measure remains well below the HEDIS mean of 53%. Limited access to ophthalmologists, optometrists, and screening equipment continues to be a barrier. PCC’s Project Access team is exploring potential partnerships to help expand retinal screening capacity for Montgomery Cares patients. 

Foot exams are also improving after a pandemic-era decline, rising from 32% in FY21 to 43% in FY24. Expanding access to podiatry services and dedicating specialty care funds for annual foot exams could help prevent ulcers, infections, amputations, and other costly complications. 

Overall, the latest results show a network that is performing well on diabetes monitoring while continuing to identify practical ways to improve outcomes. With continued investment in specialty care, nutrition support, and chronic condition case management, Montgomery Cares can further strengthen diabetes care, helping more patients avoid preventable complications and lead healthier lives. ​

This article has not been reviewed or approved by the Montgomery County Department of Health and Human Services. ]]><![CDATA[Celebrating America’s 250th Anniversary: Unity, Community, and the Strength We Share]]>Tue, 30 Jun 2026 02:58:58 GMThttps://www.primarycarecoalition.org/news/celebrating-americas-250th-anniversary-unity-community-and-the-strength-we-shareBirthdays are the perfect moments for reflection, especially the landmark ones. As our nation prepares to honor its 250th anniversary, that reflection should not just be a historical review—it should also be a celebration of  the people and communities that continue to shape its future. From the beginning, America’s strength has come from the diversity of its people—neighbors with different backgrounds, experiences, beliefs, and traditions who work together toward a shared promise. 

The lesson we take from that at the Primary Care Coalition (PCC)? Difference does not have to be division; it can be leverage. It can be finding ways to complement each other and build something greater than any of us could on our own. At PCC, we see that promise every day. Our mission is to improve the health of vulnerable individuals and families by building partnerships and strengthening systems—all toward a vision of a strong, vibrant community that supports all people in achieving healthy lives. That vision reminds us that unity does not require sameness—it requires care, partnership, and a willingness to build together. It reminds us that communities thrive when people support one another with respect, compassion, and a commitment to the common good. Or, in the words of Eleanor Roosevelt, it reminds us that "when it’s better for everyone, it’s better for everyone."  

This anniversary is also an opportunity to remember the American story is still (relatively) young, and we are writing it together. In Hamilton, the title character sings about “the notion of a nation we now get to build.” We are still those builders.  
​
​This July Fourth, we’ll be celebrating an anniversary, yes, but also our country in progress. We’ll be celebrating the neighbors who give their time, the organizations that create new ways to serve, and the community we create together every day. This anniversary, we honor the past, celebrate the present, and recommit to building a healthier future for us all. ​]]><![CDATA[Nexus Montgomery at 10: Advancing Collaboration to Improve Community Health]]>Tue, 30 Jun 2026 02:44:08 GMThttps://www.primarycarecoalition.org/news/nexus-montgomery-at-10-advancing-collaboration-to-improve-community-healthThe Nexus Montgomery Regional Partnership is turning 10 in July! That’s a decade of shared hospital investments in our community to achieve impact that no hospital could on its own: from patient navigation to quality improvement to county-wide system coordination. Shifting Medicaid eligibility rules and changing reimbursement structures have created an uncertain operating climate for hospitals, but they have continued to invest in this partnership potential.

With the Primary Care Coalition (PCC) as its management entity and staffing infrastructure, Nexus Montgomery serves as a vital collaborative platform for Montgomery County hospitals, community partners, and public-sector leaders to address shared health system challenges. Nexus helps strengthen care coordination, improve outcomes, and generate measurable value by bringing organizations to the same table—and its shared support system. Over the past year alone, Nexus Montgomery has advanced several key initiatives that demonstrate the power of partnership and data-driven action.

Strengthening Transitions from Hospital to Skilled Nursing Care

One of Nexus Montgomery’s longest-running and most successful efforts is the Skilled Nursing Facility Alliance. Through sustained quality improvement, hospital-facility collaboration, and targeted data-driven interventions, the Alliance has helped reduce rehospitalizations and improve transitions of care. The program continues to support safer, more coordinated care for patients while delivering a strong return on investment for partner hospitals.

Building the Health Care Workforce Pipeline

PCC’s Workforce Capacity Program is also helping to prepare Montgomery County residents for careers in health care. From 2023 through 2025, PCC supported 226 residents with Certified Nursing Assistant (CNA) scholarships, job-readiness training, employment navigation, and wraparound services. Many participants are also continuing their career pathways through the successful Bridge to Nursing program, creating new opportunities for local residents while helping address critical workforce needs.

Addressing Complex Discharge Challenges

Nexus Montgomery has also convened a growing coalition focused on patients who remain hospitalized after they are medically cleared for discharge. These “hard-to-place” patients often face complex barriers that require coordination across hospitals, county agencies, state partners, and community organizations. Nexus has helped move this work forward through leadership collaboratives and focused workgroups designed to improve discharge pathways, care transitions, and system-level solutions.

Improving Behavioral Health Coordination

Behavioral health remains another area where Nexus is helping partners coordinate more effectively. By using data from sources such as 911 calls and CRISP, Nexus has supported efforts to identify and better serve high utilizers of behavioral health services. Its partnership with Montgomery County Behavioral Health and Crisis Services has contributed to crisis system coordination, mobile crisis services, and 988 implementation.

A Trusted Convener for Montgomery County

Across Montgomery County and Maryland, Nexus Montgomery is recognized as a trusted convener that enables innovation and collaboration among hospital systems and public-sector partners. The Nexus Montgomery Board of Managers meets annually with the leadership from Montgomery County Department of Health and Human Services (DHHS), and many DHHS leaders serve on Nexus steering committees and workgroups. This work demonstrates how shared infrastructure can help organizations solve challenges that no single institution could address alone.

Looking Ahead: FY27 Priorities

In FY27, Nexus Montgomery will focus on three strategic priorities: aligning programs with Maryland’s AHEAD model and Population Health Accountability Plan; continuing work to improve throughput, utilization, behavioral health crisis coordination, and discharge pathways; and pursuing external funding to sustain and expand high-impact programs, including workforce capacity and patient navigation initiatives. The PCC team also works to socialize partnership results among a wider audience, showing state workgroups and organizations outside Montgomery County just how much is possible. Together, these efforts position Nexus Montgomery as high-value collaborative infrastructure for the region’s health care ecosystem. Through PCC’s continued support and partnership, Nexus Montgomery is helping hospitals, county agencies, and community partners improve care, address system pressures, and create healthier communities across Montgomery County. ]]><![CDATA[Social Health Alliance Launches Coordinated Model to Address Food Insecurity After Hospital Discharge]]>Fri, 29 May 2026 15:08:36 GMThttps://www.primarycarecoalition.org/news/social-health-alliance-launches-coordinated-model-to-address-food-insecurity-after-hospital-dischargeThe Primary Care Coalition (PCC), Nexus Montgomery hospitals, and community-based food assistance providers launched the Social Health Alliance (SHA) in February 2025 to strengthen connections between hospitalized patients and food support services after discharge.  Supported by Maryland Physicians Care, this two-year initiative is designing and piloting a more coordinated referral model. It should also generate critical insights at the systems level-- increasing visibility into community capacity and identifying patterns in unmet need.

The Alliance is initially focused on food insecurity, creating a stronger link between hospital care and community-based support. It is designed to help hospitals make more targeted referrals, provide food assistance organizations with better insight into demand, and support a more coordinated response to patient needs.

After 18 months of strategy development and planning, PCC is putting the initiative into action through three interconnected components: focus areas, patient journey stages, and workgroups. The focus areas center the initiative’s program goals—aligning supply and demand, improving coordination, and enabling case management—while also addressing community-based organization processes on the supply side, hospital workflows related to demand and referrals, and upstream screening.

These efforts are organized across three key stages of the patient journey:
​
  • Front Door focuses on visibility and access, ensuring needs are accurately identified and matched to visible, appropriate services;
  • Handshake centers on referral workflows to produce referral communications that are complete, actionable, and consistently processed; and
  • Closing the Loop emphasizes demonstrating successful patient connection to providers and receipt of services.
 
Supporting implementation are three workgroups that serve as the Alliance’s execution engine: Community Resources, which focuses on service readiness and response; Health Systems, which addresses demand generation and referral quality; and Cross-Sector Collaboration, which promotes system alignment and shared best practices. Together, these workgroups move through each stage in a common cycle, helping align supply and demand across the full patient journey. 
Picture

​The initiative’s data framework also has three parts: operations, measurement, and analysis:

  • The operations component uses the Findhelp platform to route and reroute referrals across member organizations, provide capacity visibility through manually updated program cards, and track referral acceptance status to support day-to-day case management.
  • The measurement component collects monthly data on hospital screening and referral demand as well as community-based organization referral results (received, accepted, declined, and completed), using standardized definitions that allow for comparable, aggregated reporting.
  • The analysis component examines trends in demand, completion, drop-off rates, and unmet need; identifies pressure points where demand exceeds available services; and generates evidence to support resource planning, advocacy, and future funding.

The Alliance reflects PCC’s core strength: connecting partners across sectors to create practical pathways for change. “One area where we’ve already seen measurable progress across the alliance is hospital screening rates,” says PCC Director of Community Resilience Rachel Lee.

Across partnering Nexus Montgomery hospitals, screening rates have increased from 73% to 85%. “This matters because stronger screening helps identify social needs earlier, creates more opportunities for intervention and referral, and gives us a much clearer understanding of the factors contributing to utilization and readmissions across the system.”

The Alliance creates new opportunities for collaboration between healthcare and social service providers at a critical stage: when patients require hospital care. These moments can provide valuable insight into broader community needs while offering a practical entry point for stronger coordination and case management.

“Collaboration needs to happen across the entire continuum of care, but hospitals are often where the connection between health and social needs becomes most visible,” said Rachel Lee, Director of Community Resilience at PCC. “That gives us an opportunity not only to connect patients to support, but also to better understand where the system is working well and where there are opportunities to improve coordination across the community.” The goal is to use that information to drive action and continuous improvement, so partners are not just responding to challenges as they arise, but strengthening the system over time.

Ultimately, the Alliance is working to create a more connected system of care across the county: one that better supports patients not just inside the hospital, but across the full system of care.
]]><![CDATA[Tefo Linchwe – Sharing Strengthens Communities]]>Fri, 29 May 2026 15:00:30 GMThttps://www.primarycarecoalition.org/news/tefo-linchwe-sharing-strengthens-communitiesTefo Linchwe, Director of Specialty Care Programs at PCC, helps patients navigate specialty care with clarity and compassion. He is guided by the principle of Botho, a Setswana value rooted in humanity, respect, and dignity. For Tefo, both life and work are grounded in connection.
 
Growing up, Tefo’s grandmother often reminded him, “motho ke motho ka batho”—a person is a person through other people. “For me, that message was never about intrusion, but about responsibility: the idea that we are not meant to navigate life alone,” he says. “That belief in being a good neighbor, looking out for one another, and building community continues to shape how I lead, how I serve, and how I show up every day.”
 
Prior to joining PCC in December 2024, Tefo served as a Substance Use Administrator at Johns Hopkins Hospital in Baltimore, supporting the Comprehensive Substance Use Disorders Consultation Service. In this role, he managed operational functions and led Peer Recovery Coaches within an interdisciplinary addiction care model focused on treatment engagement, recovery support, and care coordination for individuals with substance use disorders. Through that role and other professional experiences, he developed a deep appreciation for the importance of connecting with patients.
 
“Being able to talk and relate to patients, and to meet them at eye level, is essential to providing the right care,” he says. He also believes there is unique value in patients engaging with people who have shared similar experiences. “There is no substitute for having lived a shared experience. I think it brings a perspective that makes the process more effective. And, frankly, I was drawn to PCC because of its unwavering commitment to equity—an organization that not only recognizes gaps in access but actively works to close them. For me, the work is not just about healthcare delivery; it is about ensuring every person feels seen, respected, and safe seeking care. At its core, health equity is not just a goal, it is a responsibility we share.” Today, as Director of Specialty Care Programs, Tefo leads efforts to expand access for uninsured and underserved residents across Montgomery County.
 
Patients are referred through health centers and community programs, but behind every referral is a person navigating financial, systemic, and linguistic barriers—often while carrying the daily strain of simply trying to get by. “My work sits at the intersection of operations, equity, partnerships, strategy, and advocacy, with a clear focus: improving systems so that patients do not fall through the cracks in the first place,” Tefo explains. “It can be challenging because the process of getting the right care can be complicated.” In his March 2026 Brain Waves article, Improvement is Equity, he reflected on how processes themselves can become obstacles to care. As he wrote, “Each additional step in a process can become a barrier to care. Streamlining systems makes them clear and navigable for patients.”

​Building a strong team is one of Tefo’s priorities, and he approaches that work with both intention and openness. Receptive to new ideas and thoughtful feedback, he believes meaningful progress comes from a willingness to take informed risks and keep moving forward. “Progress saves lives,” he says. “You have to have the courage to experiment and push beyond your comfort zone to keep improving.”

Outside of PCC, Tefo brings the same curiosity, openness, and sense of purpose that define his work to his personal life. An avid traveler, he seeks meaningful connection wherever he goes. “Go where the local people go, and eat with them,” he says. “It gives me real insight into their culture and who they really are.” That spirit of exploration also shapes the way he invests in himself. Beyond his professional work, Tefo enjoys fitness, cooking, and is currently pursuing a Doctor of Public Health (DrPH) degree in Health Equity & Social Justice, further strengthening his commitment to advancing health equity, systems improvement, and access to care for underserved communities.

]]><![CDATA[SNF Alliance Event Celebrates Partnership Framework and Outcomes]]>Fri, 29 May 2026 14:49:20 GMThttps://www.primarycarecoalition.org/news/snf-alliance-event-celebrates-partnership-framework-and-outcomesThe May gathering of the Skilled Nursing Facility (SNF) Alliance did not just have an agenda; it had a photo prompt. (“One, Two, Three….say SNF!”) A combined meeting and recognition event, the afternoon was about more than planning the next quality improvement steps at partner facilities. It was about celebrating the partnership itself, and what we have accomplished together.

“At the heart of the SNF Alliance is a shared vision: seamless, high‑quality care across the continuum,” explains Juhi Morrison, director of clinical programs at the Primary Care Coalition (PCC). “Transitions that support patients and outcomes that improve because we are aligned, intentional, and accountable to one another.”

Partners from skilled nursing facilities and hospital transition teams show up consistently for the complex, challenging work of this longest-running Nexus Montgomery program. The Nexus Montgomery Regional Partnership is a collaboration among all six Montgomery County hospitals to jointly invest in community health and create impact no single hospital could achieve on its own. As the partnership’s management entity, PCC supports partner alignment and moves shared priorities from intention to action.

For nearly a decade, the SNF Alliance has successfully leveraged quality improvement collaboration to decrease rehospitalization from SNFs and create better patient outcomes. Partners—including 37 participating SNFs—review data, coordinate care, and problem-solve around patient care challenges.

“This work doesn’t happen by chance,” Morrison notes. “It happens because busy teams make time, because leaders are willing to share insights and adapt, and because there’s a shared belief that we are stronger together than working in silos.” That commitment has led to real progress—stronger communication, more effective use of data, deeper relationships, and improved patient outcomes. The May gathering celebrated both process and outcomes with recognition awards for partner teams. Among the categories presented were:

  • Outstanding Engagement Award to recognize facilities that showed exceptional commitment through consistent leadership and full participation across all SNF Alliance meetings throughout the year.
  • Technology Adoption Award to recognize a facility embracing innovation and effectively leveraging tools such as Real Time, CRISP, and PCC to strengthen care coordination and proactively support patient needs.
  • Collaboration Champion Award to recognize strong coordination, communication, and commitment to improving patient outcomes together.
  • Most Improved SNF Award to celebrate facilities that embraced change, leaned into the data, and made meaningful strides in improving outcomes for their residents over the course of the fiscal year.
​
“What’s most powerful about this alliance is not just what we’ve accomplished, but how we’ve done it—with trust, respect, and a genuine spirit of partnership,” says Mindy Pierce, PCC’s senior director of population health. “As we celebrate, we also look ahead. The need for strong, integrated partnerships like this one has never been greater, and the foundation we’ve built positions this alliance to continue leading, innovating, and setting a standard for what collaboration across the continuum can look like.”
]]><![CDATA[FY27 Operating Budget Increases Investment in Montgomery Cares Services]]>Fri, 29 May 2026 14:42:16 GMThttps://www.primarycarecoalition.org/news/fy27-operating-budget-increases-investment-in-montgomery-cares-servicesThank you to everyone who advocated for safety net needs in the FY27 Montgomery County Operating Budget. We’re thrilled to report that even in a painful budget year, the County Council agreed that safety net investment cannot wait.

The final operating budget legislation includes a significant reimbursement rate increase for Montgomery Cares providers (reaching 52% of the estimated cost of care) and a small increase in funding for Care for Kids specialty dental services.

Investing in the safety net means neighbors getting the care they need to stay healthier, work and pay taxes, and contribute to our shared community. It is a high-value investment for us all. These increases are not enough for genuine safety net sustainability, but they are a critical vote of confidence in these services that help hold our community together.
​
Thank you to the County Executive for including safety net investments in his recommended budget, to community members who supported them, and to the County Council for approving them!
]]><![CDATA[State Awards Third Year of Funding for Care for Kids Specialty Dental Services]]>Fri, 29 May 2026 14:27:30 GMThttps://www.primarycarecoalition.org/news/state-awards-third-year-of-funding-for-care-for-kids-specialty-dental-servicesFor the third year in a row, the Maryland Department of Health, Office of Oral Health has awarded funding to support specialty dental care for Care for Kids (CFK) participants. Not only will this Fiscal Year 2027 funding support much-needed complex care; it creates pathways for routine oral healthcare for these children.

Specialty dental care unlocks regular dental access

The Care for Kids (CFK) program offers more than access to medical primary care—participants have access to routine oral health services as well. The Montgomery County Department of Health and Human services operates dental clinics in five locations, providing an important access point for uninsured residents. Yet many CFK participants present each year with dental needs that are too complex for the county dental clinics to address. Routine dental access for these children requires an extra intervention.

When County dental staff identity CFK participants who need complex care, they refer them to the Primary Care Coalition’s (PCC) CFK Nurse Case Manager for specialty dental service coordination. For many participants, an initial course of specialty dental treatment can help ensure access to routine primary dental care as they grow.  

Program serves children from low-income households

PCC administers the Care for Kids (CFK) program, a public-private partnership serving children from households earning less than 250% of the Federal Poverty Level and who are uninsured. The program served 10,062 children in fiscal year 2025 (FY25), with participants representing a diverse population of children from 91 different countries of origin and 47 different primary languages. Spanish was the primary language for 92% of children.  

Many new CFK enrollees have only recently settled in our community. Of the 1,400 newly-enrolled children, 72% (1,008) were resettling in our community following detention at the US/Mexico border.  

Household income was below the Federal Poverty Level (FPL) for 59% of FY25 participants. Put in context, the 2023 FPL for a similarly sized household of $30,000, versus the 2023 self-sufficiency standard of $111,536 for two adults and two school-aged children, according to the Maryland 2023 Self-Sufficiency Standard Calculator. This is not a patient population who can self-pay for specialty dental care.

PCC bundles funding to meet service needs

In FY25, County dental staff identified 64 children in need of specialized care, with an average cost per child of more than $1,500. CFK collaborated with contracted providers to ensure these children received appropriate treatment. Of those children, 33% were aged 13-19, 58% were aged 6-12, and 9% were aged 3-5. The number of patients includes 6 children receiving oral surgery, 3 children receiving endodontic services, and 2 receiving multidisciplinary services (ex. endodontic treatment and oral surgery). Treatments provided included extractions, composites, crowns, pulp vitality tests, pulpotomy, space maintainers, seals, films, occlusions, and different levels of sedation. To provide the total needed care—valued at $106,148—PCC leveraged multiple funding sources, including County funding (55.5% of the total), grants and donations (36.3%), and discounted/donated services (8.2%). Thank you to the Montgomery County Department of Health and Human Services; the Maryland Department of Health, Office of Oral Health; the Delta Dental Community Care Foundation; and partner providers for making this care possible!  
​
These combined efforts mean most children will be able to use the County dental clinics for routine care in the future—providing a regular dental home to support healthy development.  
 
This article has not been reviewed or approved by the Montgomery County Department of Health and Human Services.]]>