by Annice Cody, President and CEO

For people with health insurance, colorectal cancer screening is an unpleasant “to do” item every 5 – 10 years. For those without insurance, screening and, if needed, access to diagnostic and treatment services may be aspirational, not something easily checked off a list.

Through public and private partnerships, the Primary Care Coalition (PCC) has stitched together a patchwork of services to improve access to colorectal screening, diagnostic and treatment services. Our approach leverages partnerships to make the most of committed resources and serve more patients, more effectively. Let’s look at how that works.

Rather than beginning with colonoscopies, which are expensive and invasive, Montgomery Cares patients are offered an initial screening with in-home stool tests. By reserving colonoscopies only for those whose at-home tests are positive, we can extend the Montgomery County Colorectal Cancer Screening Program colonoscopy budget. For patients who require diagnosis and/or treatment, the Montgomery Cares program uses the Project Access specialty care team — staffed by PCC — to apply for Maryland Cancer Fund grants, which provide up to $40,000 of care per patient. Working collaboratively with the County and the State helps Montgomery Cares and our public partners to make the most of limited resources and preserves Project Access treatment funds to serve the wide range of other specialty care needs in our patient population.

A recent private partnership with Exact Sciences — makers of Cologuard — helped PCC further leverage specialty care resources. The Cologuard tests are more sensitive in detecting cancer and precancerous polyps and need to be repeated only every three years. The company offers the tests at no cost, provides blanket eligibility for Montgomery Cares patients (instead of requiring separate applications for each one) and reminds patients about their screening schedule. This partnership reduces the cost of in-home screening, more accurately targets patients who need colonoscopies, and saves case management time for the Project Access team.

Cancer care is complex, and for uninsured patients, social and financial needs exacerbate the complexity. By thinking about the care continuum systemically, rather than as distinct modalities and providers, PCC generates a big win: in patient and health center time, screening, diagnostic and treatment dollars, and very likely in patient outcomes. Those are returns worth celebrating.

by Stephanie Narayanan, Director of Development and External Relations

What do you get from a storytelling show besides a great evening and a YouTube video? If it’s PCC’s 2025 storytelling show, the answer just may be a timely primer for navigating into the new year. Consider these thematic highlights as the reminders we all need right now:

Being an early reader like Razia Alizada sounds phenomenal…until you start failing third grade because deciphering words isn’t the same as understanding them. The bilingual care managers in our Montgomery Cares Behavioral Health Program are an important community resource—and they’re incredibly difficult to replace when natural turnover happens. What has always felt like a program strength can feel like a risk area now. But it remains a challenge worth facing because offering patients the care they need is worth it.

Not having the right answer right now doesn’t mean we won’t get there. As Corey Smedley and Wenjing Zhang reminded us, we need the humility—and the courage—to fail and learn from it. Dr. Kisha Davis rightly told the Montgomery County Council that our local safety net cannot backfill for all the resources we are losing to changing federal healthcare policy. But that doesn’t mean we can’t do anything. The ongoing Access to Care Sessions we’re co-leading with our County partners—and PCC’s work in general—is about staring down fear and uncertainty and asking, “How can I help?”

Dr. Nina Ashford’s best efforts at implementing all the wellness tools were no match for post-partum depression, and that’s the strength of her story. There’s a parable we often use when talking about PCC: the elephant and the blind men. Each has a vastly different description of the same animal based on the one part he can feel. And in my mind, that’s just describing the contours of the problem, not designing the solution. If we’re intent on solving just for the things we as individuals can see, we will miss the possibilities of our collective vision.

Bridget Howe told her story about the kind of people you meet volunteering—both the delightful seniors she served and her peers over the years—and our intrepid leader has repeated Eleanor Roosevelt’s line that “When it’s better for everyone, it’s better for everyone.” If we value living in a community that cares for each other, that’s the investment we should make. 

The power of our storytelling show is not (just) to brag about our incredible team and partners. It is to remind us all that none of this is possible in isolation. That, in fact, as last year’s storyteller Edwin Rich shared, disconnection can be a kind of disease.

Yet, as simple as all that sounds—be brave, work together, community is everything—none of it is easy. And for all its philosophical simplicity, operationalizing it is incredibly complex. It involves creating enough structure and muscle to keep a movement, well, moving, without creating outsized burdens or new breaking points from overdone rigidity.

As we reflect on the year (almost) behind us and prepare for the year to come, let’s remember how much we need a diversity of roles and gifts and voices. To borrow from politics—and a past storytelling show—we really are stronger together.

Please also keep that in mind this giving season, and don’t give from a place of charity. Supporting community-based organizations is important, but it’s not really a gift.

It’s an investment. In our communities, our values, our collective vision.

More importantly, as County Councilmembers Balcombe and Friedson observed in a November hearing, the helpers and the ones being helped are often the same. Or, as we’ve said before, the storytelling show tends to remind us that we all move between places of need and strength. Vulnerability touches us all, but it doesn’t have to trap us. Donate your dollars (#MontgomeryGivesLocal) as an investment in our collective future. The return is real.

The problems identified here aren’t new, but publicly naming them is. Among the five new measures reported for FY24, the report links three of them to existing resource gaps:

• Retinal screening for patients with diabetes has been discussed as a problem for years. PCC even applied for foundation funding in FY19 and FY20 to purchase retinal cameras as a bid to provide a low-cost, on-site screening mechanism within primary care. But the cameras were not funded, and the problem has remained. It is an important health maintenance measure that does not happen because our primary care partners lack a viable routine way to provide it. 
• Foot exams for patients with diabetes are possible in a primary care setting, though they may be hard to include among multiple competing concerns in a single visit. Additional specialty care funding for podiatry visits would help ensure higher exam coverage.
• Pneumococcal vaccine coverage can help prevent serious—possibly fatal—infections, but insufficient funding to purchase and administer these vaccines has led to very uneven vaccine coverage across the MCares partner network.  

The consequences of these gaps are significant, and they cannot be bridged by health centers alone.

by Stephanie Narayanan, Director of Development and External Relations

My favorite part of Alabama history* is an elegant marble monument honoring…a bug. It’s not (just) the idea of memorializing a beetle that appeals to my inner storyteller; it’s also the quirky reminder of a timely lesson.

The boll weevil was not just an Enterprise, Alabama problem, but an environmental change that threatened US cotton production for the better part of a century, according to Smithsonian Magazine. What was different about Enterprise, though, was its response: Instead of focusing their energies on preserving cotton fields, farmers pivoted—first to peanuts, then to a range of crops that diversified local growing.

Hence, the boll weevil’s marble monument, which reads: "In profound appreciation of the Boll Weevil and what it has done as the Herald of Prosperity."

I’m not suggesting we celebrate the very real crises that are likely coming, but I am suggesting we focus on where there are opportunities.

In an ideal world, we’d be building up new models out of abundant resources—a strategy PCC has been working on steadily since before the federal funding cliff. Things are not ideal. We continue the work anyway. 

We cannot keep underfunding nonprofit operations—the “Nonprofit Starvation Cycle”—but we can think hard about where strategic partnerships benefit both an organization’s operating capacities and its beneficiaries. We need to get to a place of doing more with more. We can start by finding ways to leverage the resources—including backbones—we  already have.

Community-building is an ecosystem effort. Diversification is not just a funding necessity but an operating imperative. We all need to be clear about the strengths we bring and the gaps others can fill. PCC has built trust by our insistence that we don’t try to replicate the work other organizations are doing. It’s a waste of energy on unnecessary competition when we could be building out balanced efforts. At PCC, we are focused on the value we can add. We are focused on the long-term health of a thriving community. 

 
*Being Alabama-born and raised, having a favorite Alabama history moment is not as random as it sounds.

by Annice Cody, President and CEO
With all due respect and apologies to Commanders fans, I was intrigued by Binyamin Applebaum’s contention that sports stadiums have become “monuments to the poverty of our civic ambitions.” He argues that glossy projects like stadiums are decoys for the real work of building communities. I believe PCC offers the opposite: An abundance of civic ambition to build a lasting infrastructure that supports our shared desire for a stronger, healthier community.

As the County Council’s budget decisions were wrapping up in May, and even as he warned of a tough budget year ahead, Councilmember Gabe Albornoz said something that has stuck with me: “There’s nothing wrong with Montgomery County that can’t be fixed by what’s right with Montgomery County.”

That’s the spirit PCC was founded on. When our founders looked for ways to serve uninsured neighbors, they didn’t start with what was missing. They started with what we already had—and asked how we could use it to help more people.
It’s the PCC version of the "abundance mindset": a deep respect for the community we have, and an unfailing belief that it can be big enough, strong enough, and generous enough to serve us all.

But that doesn’t mean this work is easy.

When Leslie Graham stepped into this role in 2014, she was concerned about environmental uncertainty. As I step into this role today, uncertainty still exists.
We’re navigating a time of deep political strife, uncertain healthcare funding, dramatic shifts in immigration policy, and a broader climate of retrenchment and protectionism. Naturally, I’ve asked myself: What does this mean for PCC and how should we respond?

When the world feels chaotic, I try to simplify my response: How can I help? And I often find guidance in the wisdom of the Jewish prophets in the Talmud: “Do not be daunted by the enormity of the world’s grief. Do justly, now. Love mercy, now. Walk humbly, now. You are not obligated to complete the work, but neither are you free to abandon it.”
Pretty good advice, right? So, what can you expect from the Primary Care Coalition as we move forward?

As complexity increases, I focus on “no-regrets” priorities—initiatives that will serve us well no matter what the future holds. Let me highlight four of them:

We may not know exactly what lies ahead, but we can be fairly certain that funding for health and social services will tighten. That makes stewardship of resources more important than ever. To make the most of our resources, we will seek opportunities to improve performance, to share best practices, and to take advantage of economies of scale to be effective stewards of our community’s resources.

by Annice Cody, President and CEO

I’m still figuring out how to tell people what I do now as CEO of Primary Care Coalition. By that I mean the challenge of explaining the organization I’m leading. A broad scope of partnership work makes it difficult to be both accurate and concise. How much narrative weight do I give legacy programs that focus on the uninsured, versus emerging work that looks more comprehensively at vulnerability?

Maybe it’s best to start the conversation with the purpose of our work, rather than the details of it. Perhaps that’s the sweet spot for engaging people in its importance.  

So what is that purpose? Our vision is a vibrant community that supports all people in living healthy lives. It would be easy to focus on the health part of that vision, particularly in light of the day-to-day work we do, but I wonder if that isn’t somehow missing the point. Our lens is health and health care, certainly, but our vision is one of community.

The thing I like about health as a scaffolding for community is that it’s relatable. Not everyone knows the strain of housing insecurity, even if we all recognize the importance of home. But I can’t think of a single person who hasn’t needed health care. And in our American system, I’m hard-pressed to think of anyone who hasn’t struggled at some point to get the healing they need.

For as broad and wily as the notion of community can be, it’s always built around something shared: geography, history, values. Pursuing health is a shared experience, and most of us realize we’re all only one bad-luck diagnosis away from leaning heavily on healthcare.

A former board member would talk about his emotional connection to PCC in terms of Care for Kids. He realized that parents and guardians with limited resources still wanted the same healthy futures he had wanted for his children. Whatever the difference in their material circumstances, their visions and motivations were shared.

As we watch systems crumble all around us, it is tempting to despair. In the same way that watching cancer cells metastasize could feel like an inexorable march toward doom. But the antidote to that despair already exists: community. Our ability to lean on connection is the breakthrough immunotherapy for this moment.

We are each other’s answer. PCC’s role is to remind us of that.

In last month’s brainwaves we talked about PCC as a backbone, and that’s certainly true. But the piece that resonates most deeply for me is this: PCC is a connector. Whether it’s elbow to femur or grassroots to treetops, we specialize in bringing together a whole that eclipses its parts.

Consider the evidence around collaborative care as suicide prevention publicized by Shatterproof and the Bowman Family Foundation: in addition to prior research on cost savings, a study by Kaiser Permanente found a 25% lower rate of suicide attempts among patients who had received a collaborative care-style intervention than those who had not. Collaborative care, which PCC has adapted for our local safety net, is not an elaborate model. At its core, it is a care delivery model focused on primary care and mental health providers working together to leverage modest resources effectively.  

Community is the ultimate multiplier. As uncertainty becomes the standard operating environment, PCC will be focused on combining the work we do best—connection—with an eye toward innovative collaboration. We’ll be focused on transforming our collective resources into the community we want to be.

The safety net is our community’s herd immunity, and we don't necessarily notice when it starts to thin. Slowly, vaccine hesitancy goes up, and coverage goes down. Experts warn we’re below the threshold, but everything feels mostly fine. Things hum along, until they don't. In a matter of days, our first detected case can explode into an outbreak.

We are seeing the safety net thin. A sudden surge in newly uninsured residents dropped from Medicaid rolls is not a challenge they can absorb. We are hearing clinics say privately that they're struggling—not all of them, but some. We've seen even large FQHCs undergo strategic reorganization to get ahead of possible Medicaid reductions.  These are all signs we may be losing the herd. The system as we’ve known it cannot hold much longer, and the emergency is now.

We know there are many emergencies out there. The good news is, we are an incredible community, and we can do this. But we have to do it together.

Our partner health centers know this is a tough budget year and fiscal prudency is essential, but it cannot be a flat year either. (As anyone reliant on cost-of-living adjustments knows, flat is actually another loss.) They need enough of an increase to keep going. They need a promise they're not forgotten: that they are working in partnership, not alone.

This article has not been reviewed or approved by the Montgomery County Department of Health and Human Services.