by Stephanie Narayanan
Senior Development Manager, Primary Care Coalition
​​Growing up, my family was super active in the local chapter of a national diabetes nonprofit, JDRF. Every year, we’d show up to staff and participate in the organization’s fall walk-a-thon. There were ridiculously early start times, and we were never done before early afternoon. But it was a thing we did because type 1 diabetes had touched our family, and we knew it was worth it.
 
There are far easier ways of raising money, but once you’ve established a core audience, these events can be a real moment of community. Those long Saturdays felt almost like family reunions, showing up and seeing other folks whose families had also been involved for years.
 
As powerful as those gatherings can be, there are also important ways they fail—for both attendees and organizations:

• They’re complex to organize and impossible to staff unless you can mobilize significant numbers of volunteers. That makes them tricky for smaller nonprofit organizations.
• They often exclude people with mobility challenges by default.
• They rely on local community—or a series of local chapter events—and make it difficult for supporters living afar to actively participate.

 
None of these challenges are reasons to discount charity race events as a whole, but they offer ideas for improvement. Process improvement happens to be a PCC specialty.
 
Here's how we’re thinking about the Virtual 5K as an event for this year, and (hopefully) beyond:

• We’ve structured it to be welcoming to anyone, anywhere, with any degree of mobility. Do we expect to have significant numbers of participants completing a 5K with a walker? Maybe not, but we’ve structured it so they really could, at least over the 5-day span of the event.
• Location is flexible. Folks for whom transit is a challenge can stick close to home. I can corral my family—those I’ll be seeing immediately after Thanksgiving, and those I won’t—to actively support a cause that matters to me.
• So is the event size. There’s nothing to say this has to be a solo or very small group event. We would love nothing more than to see participants do this together. If you're interested in spearheading a gathering, I'll happily spread the word.

 
The first COVID October, my neighborhood started a Halloween parade. It was pretty bare bones: some organizers put out the call for folks to show up at a certain time to follow a set route, and they encouraged folks along it to watch and/or offer candy from a safe distance. But the experience was better than any Halloween of my childhood or my children’s. It also had some real practical benefits. Suddenly, living on one of the busiest streets didn’t handicap us from seeing all the neighborhood kids dressed in costumes. Folks who don’t do Halloween had an easier opt-out with less door-to-door action. Most of all, we established something that’s both very rooted in our neighborhood and accessible beyond it.
 
I don’t want to go back to the Halloweens of before. The new ones are so much better.
 
The pandemic broke a lot of things. But as many have suggested, that forced disconnect from the way things used to be has given us a chance to reimagine what they could be. Nearly 3 years in, you may be feeling maxed out on virtual anything, but I want to make the case for our Virtual 5K.
 
It’s not a poor substitute for in-person gathering. It’s an inclusive new model for moving together.

​Click on the image below to register.

by Leslie Graham
President and CEO, Primary Care Coalition
​​Primary Care Coalition kicked off our 30th Anniversary year on November 10th with a live storytelling show. The event had it all: an official county proclamation in honor of 30 years, remembrances of trailblazing PCC employees, and amazing stories from our staff and partners. It was the perfect way to start an anniversary year, celebrating the community impact we have achieved and looking forward to our next big ideas.​

Thank you to everyone who was able to join us. It was such a joy to gather in person again! For those who weren’t able to be there, it’s not too late! We will be presenting a special streaming encore via YouTube on Monday, November 28th at 7:30 pm.

Some of the stories will give you a sense of the work we do, but the real takeaway is connecting with who we—and our partners—are and why we do this work. Our work is to make change at the systems level. To some this can seem conceptual or analytical in nature.  Yet systems are made up of people, with motivations and experiences we can all connect to. That is the part of this storytelling show I love so much and why I’m so thrilled we were able to return to it this year.

One of our storyteller, Sergeant Chad Matthews, had an entire career trajectory before he ever joined the Montgomery County Police Department. A single flight changed the course of his life, but even that change wasn’t linear. He experienced different areas of the police force before he became Crisis Response Support Section Supervisor, and all those experiences shape the way he approaches his job now.

Our Board Chair Shawn Bartley owns a small law firm imbued with his big personality. He is the kind of person who has never met a stranger, and his ability to connect with his community literally saved his life.

One of my favorite stories was one I’ve heard many times before but never quite like this. Philip Jackson visits PCC most years to present the Mary C. Jackson Award in honor of his late mother, one of PCC’s early staff members who helped create many of our enduring programs and our culture of ‘Good Works, Done Well”. I knew the work of PCC, and being with her PCC family, gave Mary such a sense of purpose that she continued throughout her illness and almost right up to her death. What I didn’t know was how hard won that sense of belonging really was or how her own sobering life experiences drove Mary’s energy to make new services a reality for others.

PCC is truly a coalition of many, who over the past 30 years and for the decades to come, seek to make lasting changes to the systems that influence the health of vulnerable individuals and families. In this season of gratitude, it was beautiful to be reminded that if you can connect with your own unique history of struggle or loss or luck, if you can use that combination of experiences that is yours alone to make systems work a little better for everyone, you’re a part of our coalition.   

Whether you are new to learning about PCC or a long-time supporter, I invite you to be awed by the personal experiences in our storytelling show. The virtual gathering to watch the show highlights is on November 28th, and I can’t wait to “see” you there. 

In this season of giving, I also invite you to consider a gift of support to PCC. Systems level work and coalition building is essential and impactful, as our 30 years and our storytellers have proved.  Yet it is often overlooked for the immediate satisfaction of one person getting services today.  PCC works to ensure all in need have access to high quality healthcare and related services well into the future.  Thank you for being part of our coalition.

We talked with Dr. Carol Garvey, a retired physician and former Montgomery County Public Health Officer to unpack the latest guidance on flu and COVID vaccines. Dr. Garvey also co-founded the Primary Care Coalition and remains a member of our Emeritus Board.
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With flu season starting and Covid still in the mix, when is the best time to get a Covid booster and annual flu shot? Can you get both vaccines at the same time?
Flu season is already starting and now, before the end of October, is the best time to get protected with a flu shot. The season usually peaks between December and February, often continuing until May. And yes, it is safe and convenient to get both a flu vaccine at the same time as a Covid-19 booster if it’s been at least two months since your last Covid vaccine, and you have not recently had Covid.

Anyone who has had a solid reaction to the Covid-19 vaccination in the past may prefer to get their booster on a different day since studies have shown that individuals who get both vaccines on the same day can experience a slight (8%-11%) increase in the Covid-19 vaccine side effects such as fatigue, headache, and muscle aches. However, those side effects were mild and resolved quickly. Most people experience little to no side effects with the flu shot.

If someone has just recovered from Covid, should they wait before they get a booster?
It’s best to wait three months after having Covid before getting a booster or the next Covid-19 vaccine in order to maximize immunity. Start counting from the date symptoms started or, if there were no symptoms, count from the date of the positive test results.

What can we expect this flu season?
We have the advantage of seeing how the flu season transpires in the Southern Hemisphere. Australia has just had its worst flu season in five years, so we are expecting a bad flu season here after experiencing relatively mild flu seasons during the pandemic. That’s why we are recommending that everyone over six months protect themselves with a flu vaccine to avoid serious illness.

The flu vaccine has been shown to reduce the risk of having to go to the doctor with the flu by 40% to 60% when the vaccine viruses are similar to the circulating viruses, according to the Centers for Disease Control and Prevention (CDC). We also recommend that people continue to reduce their risks by avoiding close contact with people who are sick, continuing to practice frequent handwashing, and practicing other good health habits.

What is the most compelling reason to get a flu vaccine?
A flu vaccine can prevent an illness that not only makes you feel bad for a few days to a week or more but can head off complications such as bacterial pneumonia, ear infections, sinus infections, and worsening medical conditions such as congestive heart failure, asthma, or diabetes. It’s not always “just the flu.” According to the CDC, a 2022 study showed that a flu vaccine reduced the risk of severe life-threatening influenza among children by 75%. The CDC also pointed to other benefits of flu vaccinations, including a 2021 study that showed that among adults hospitalized with flu, vaccinated patients had a 26% lower risk of Intensive Care Unit (ICU) admission and a 31% lower risk of death from flu compared with those who were unvaccinated.

Annual flu shots are the best defense against flu-related illness, hospitalizations, and death. They are offered in a variety of locations including clinics, pharmacies, grocery stores, and the Montgomery County government.

What do you say to people who are hesitant about getting another Covid-19 booster?
Immunity wanes over time, and it’s important to stay protected from serious illness, hospitalization from Covid, and even death. Covid-19 vaccines are safe and effective for everyone older than six months. It is especially important to get updated protection with a booster if you fall into a category where you may be at higher risk of complications. That includes older adults, people with disabilities, and those with diabetes, heart disease, cancer, and weakened immune systems. For more information about the Covid-19 vaccines and booster

Despite the challenges of the COVID-19 pandemic, our community’s most vulnerable residents have continued to receive high-quality health care thanks to Quality Improvement Manager Temi Oshiyoye and others who have worked hard to maintain quality measures for the best care outcomes.  

Temi, tell us about yourself. How did you end up working with the Primary Care Coalition? 
Over the past 13 years, I have worked in different areas of public health, from community research to healthcare management. I’ve also worked on various topics within these areas, like tobacco cessation, rural health, and quality improvement.  

My educational background includes a bachelor’s degree in psychology, a master’s in public health, a post-graduate certificate in patient safety and quality, and current enrollment in the Franklin University doctoral program in healthcare administration. I am also a certified Health Education Specialist and Six Sigma Yellow Belt.  

My training is broad, and it has involved so many pieces of the public health system.  I ultimately decided to work with PCC because of the mission. I was drawn to PCC’s systems focus because I believe infrastructure development is a cornerstone for a healthy community.  

Why are you passionate about data-driven quality improvement?  
Quality improvement (QI) data tells the story of what is happening currently and what can be done to improve. The QI process offers tools for improvement efforts and, ultimately, better health outcomes. The beauty of QI is that if a specific tool doesn’t produce the desired results, we can try another one if it’s not working the way we planned. It’s very much a living process in that way, and the focus is not on reaching a finite metric but on constantly finding ways to do better. 

Using your work with Skilled Nursing Facilities (SNF) as an example, could you describe how using data can improve clinical quality? 
Data reveals or explains. For example, a SNF might know it has a high readmission rate, but it might not know why. Reviewing the data might show that readmission rates are reasonable for most patients but significantly higher for those with diabetes. Identifying that trend helps the SNF focus its efforts on the needs of patients with diabetes and testing strategies to improve their care. Since the process began from specific data, the SNF can use that same baseline to evaluate the effectiveness of their changes to diabetes care. They’ll keep reviewing and testing and create continuous improvement opportunities.   

You worked with Skilled Nursing Facilities for a long time, but during the COVID-19 pandemic, your expertise in quality improvement translated to other types of settings. Describe how your approach and philosophy of quality improvement translates across care settings.  

Historically QI tools have been used in many industries, from automobile manufacturing to healthcare. QI is a multidisciplinary, system-focused, and data-driven approach to understanding and improving outcomes. I look at a problem and think, how can I improve the quality, reduce cost, and ensure good results? This is how I have been able to move across sectors and projects within PCC and throughout my career. For example, early in the COVID-19 pandemic, PCC began working on infection control measures with group homes serving individuals with intellectual and developmental disabilities. In addition to my role with the SNF Alliance for quality improvement, I also worked with group homes. They have some of the same congregate living risks we saw with SNFs, but without the healthcare expertise. We were able to develop a learning collaborative and work with the group to understand their needs and implement quality improvement projects. These homes are their own systems that operate from sets of policies and procedures. We were able to think through those together to decide where testing new procedures might protect staff and residents better.  

What, in your view, are the biggest challenges? 
The constant change in SNF leadership—within the facility and on a corporate level—is hard. This continuous change in leadership sometimes presses the reset button on all our work to establish collaboration and partnerships. It’s important to maintain quality improvement progress during those transition periods when leadership changes mean rebuilding relationships.  

What have you found rewarding about this work?  
Having the data means being able to show improvement in patient health outcomes. Being able to see real change is gratifying. Apart from the numbers, hearing success stories from the SNFs themselves is rewarding. Because we have a collaborative learning setting for quality improvement, SNF representatives can also help colleagues at other facilities learn from their intervention experiences. The work we’re doing can have life beyond a single healthcare organization.  

For those who are interested, more information is available online about clinical quality and the Montgomery Cares FY21 Performance Measures. 

Despite significant healthcare disruption from the global pandemic, Montgomery County's safety net clinics continued to perform at a high level, according to the FY 2021 Montgomery Cares Clinical Performance Measures released recently by the Primary Care Coalition (PCC).

This is the 14th year that PCC has published annual performance measures for the Montgomery Cares program. Mask mandates and fluctuations in COVID-19 cases posed significant challenges for the clinics during the year, including a 20% decrease in the number of patients and a 15% drop in total visits due to patient reluctance to seek in-person care and preventive screenings. Nevertheless, the clinics served more than 19,500 low-income, uninsured adults in more than 53,000 separate visits during FY 2021. Clinical performance met or exceeded national benchmarks in more than a few areas.

The patients in the Montgomery Cares program receive services through 10 independent safety-net primary care organizations, six hospitals, the Montgomery County Department of Health and Human Services, the Primary Care Coalition clinics, and community-based providers and groups. Medical directors and clinics had to be creative, innovative, and nimble in order to deliver critically important services during the pandemic.

The program's medical directors reviewed and adopted clinical measures to reflect appropriate updates to the Healthcare Effectiveness Data and Information Set (HEDIS) benchmarks, as they do every year. They also met quarterly to discuss Montgomery Cares' specific quality-related issues, including outcome measures, best practices, challenges, resources, and collaboration opportunities. In addition, on-site Quality Assurance Reviews were performed.

Clinics continued to meet or exceed HEDIS Medicaid benchmarks in FY 2021 for diabetes testing and blood pressure control, although disparities persisted by race, gender, and ethnicity. The clinics also improved breast cancer screenings, although differences were again noted by race. The screening rate for white women (64.38%) exceeded the benchmark of 59%, but the rates for Black women (54.27%) and Asian women (47.14%) fell short. Cervical cancer screenings aligned directly with the NEDIS benchmark in FY 2021.

Diabetes was diagnosed in nearly 5,200 (26.3%) of the Montgomery Cares patients, up 10% in FY 2021 from the previous year. Another chronic health issue that affects life expectancy is hypertension (high blood pressure), which was diagnosed in nearly 5,500 (27.87%) of Montgomery Cares patients in FY 2021, a decrease of 3% from the previous year.

Although colorectal cancer screenings for men and women had been increasing until FY 2019, rates were slightly lower for FY 2021 and FY 2020, likely attributable to patient reluctance to schedule preventive services. 

As part of the robust collaborative care models that Montgomery Care participants use, patients are also screened annually for depression. In FY 2021, 90% of active patients received depression screening within 12 months of the performance report.

Over the past decade, the Montgomery Cares program demonstrated consistent improvements in clinical quality, according to the report, which is available online.

The emphasis that the program’s medical directors and clinics place on excellence in all aspects of service delivery was guided by strong clinical measures. That resulted in consistent and sustained performance improvements over the past decade, despite the global pandemic.

Tell us about yourself. How did you end up volunteering with the Primary Care Coalition?
I retired from full-time work two years ago after 23 years as an Army physician and researcher and 20 years as a civilian in drug and vaccine development and early-phase clinical trials. My own physician father was a passionate supporter of PCC, as well as a co-founder, so I contacted PCC and said I was looking for a role as a volunteer.
 
Why are you passionate about data driven quality improvement?
Passionate is a strong word to use concerning data-driven QI. However, my career in drug development has given me familiarity and respect for data-driven decision making. It is important to understand what the existing HEDIS measures used by PCC tell us about what we are doing well and what we could be doing better, and to share ideas for change among the clinics.
 
The behavioral health program appears to be one of the real successes documented by HEDIS data. In this case the QI process provides not only the incentive to diagnose these problems, but the availability of in-clinic behavioral health resources allows us to treat them. In other conditions, such as colon-cancer screening, we seem to do a good job of screening, as measured by HEDIS, but have scarce access to subspecialty resources to follow up with colonoscopies for positive screens, and optimally affect health outcomes.
 
Using your work on medicine access for diabetic patients as an example, could you describe how using data helps improve clinical quality?
The standard of care for type 2 diabetes has been revolutionized over the past 10 years with the use of two new classes of drugs as add-ons to diet, weight-loss, exercise, and older generic drugs to improve blood sugar control. These new drugs clearly reduce the risk of heart problems and stroke, of progressive renal impairment, and of fatty liver disease. Unfortunately, these branded-drugs are unaffordable for most of our patients, and access through MedBank on a patient-by-patient basis takes a mountain of paperwork and a long time. This process is especially uncertain for our undocumented diabetic patients, who qualify for very few of the manufacturers’ programs.
 
There are well-over 3,000 patients in the McCares system with a diagnosis of type 2 diabetes.  Most are treated the traditional way: first with inexpensive oral agents and attempts at diet modification and weight loss, then the addition of injected insulin, which usually increases appetite and weight gain, and introduces the risk of low-blood sugar incidents.[SN1] 
 
We could identify, by a lab measure called the calculated GFR, those diabetics and hypertensives who have significant kidney disease, and prioritize them for access to these drugs.  We could also identify another priority group, based on calculated cardiac risk scores (AHA ASCVD risk calculator). And performing this calculation could be included in the future as a QI measure for diabetes patients (just like control of blood pressure is).

However, all such treatment decisions remain with the individual providers, and practices will of course vary widely.  I also think it important to promote the use of a simple urine test called the albumin/creatinine ratio, which is excellent at diagnosing early diabetic
kidney disease, and look at that data across clinics. 
 
Of course, while these data tell us which patients might benefit most from treatment with one of the newer drugs--called SGLT-2 inhibitors and GLP-1 agonists--it does not solve the problem of access to drugs, which cost 30-50 times more per month than generic metformin and insulin.  
 
What, in your view, are the biggest challenges?
As I mentioned, access to newer and better branded medications for certain conditions is a major problem. As January 2022, only about 60 of the hundreds of diabetics at our clinics who might benefit from newer branded drugs had obtained access through MedBank and manufacturers’ special need programs. It would be immensely helpful if either a philanthropic foundation would provide dedicated funding to purchase these drugs for all patients who meet priority criteria or if several manufactures would agree to donate medication to any such patients. Obtaining access to the drugs on a case by case basis requires immense amounts of documentation, consumes a lot of time and resources, and greatly restricts our use of these better drugs. 
 
Another issue is the lack of support by the larger medical community for subspecialty care. Primary care physicians provide a medical home and continuity of care for patients, and manage many common medical conditions. However, if a patient has a positive colon Ca screening test, a positive mammogram, or blood in the urine, then a referral to a gastroenterologist for a colonoscopy, a surgeon for a biopsy, or a urologist for cystoscopy is essential. There are many, many other conditions requiring subspecialist referral as well. While Project Access is continually trying to recruit more sub-specialists willing either to volunteer in a clinic or to see McCares patients in their own practices, access to specialty care remains a serious issue limiting the quality of care for our patients. 
 
Finally, there is a severe national shortage of primary care physicians, in internal medicine, family practice, and pediatrics. This will not be remedied anytime soon, since compared to medical specialties, primary care remains under-resourced (and underpaid) and physicians in training know this kind of practice can be more poorly paid, stressful, and prone to burn-out.  A large number of primary care providers took early retirement during the COVID period. Many independent practices failed. This has increasingly shifted the burden of primary care to nurse-practitioners and physician’s assistants, as is common practice in our clinics. But the shortage of primary care physicians has greatly increased demand for these other providers, and made it more challenging to staff safety-net clinics.
 
How difficult is it to determine which measures to focus on, and how long does it take to gather meaningful data? 
Most of the clinic directors are accustomed to collecting the data for the current HEDIS measures and would need to see a strong case be made for the need and benefits of any new measures. I do feel the focus on these specific HEDIS measures may not capture the adequacy of care for common conditions affecting working age populations (osteoarthritis, asthma, COPD, sleep apnea, and migraine, etc). Our quarterly meetings have not much discussed the issues, however, as they have been virtual since the onset of the COVID pandemic. A large Zoom call is a difficult setting to discuss these issues and agree on action plans.  
 
Many measures would be easier to track if all clinics used the same type and instance of electronic medical record (EMR).  PCC can directly extract a lot of information about diagnoses, lab results, medications, etc directly from the shared EMR.  Unfortunately, each clinic in the network needs to update or sometimes change EMR systems, to meet its needs, and the number on the shared database is bound to decrease further. The result will be an increasingly laborious process to transfer data from the different EMRs into a PCC database, and then to produce the HEDIS measures. A June Pulse article about Care for Kids  behavioral health highlighted these same issues: “Simply mapping how information is entered and determining whether or not it represents extractable data took more than one grant year during the pilot project.”
 
QI data must be collected for a half-year or longer to provide a baseline against which to measure the impact of new QI initiatives.  Unfortunately, the small number of in-person visits and other impacts during the first year of COVID-19 severely skewed our data on many quality measures. 
 
What have you found rewarding about this work?
It is rewarding to do any work which expands access to medical care to our hard-working, often uninsured, MCares patients. One individual can only do a little, and may often be frustrated by the recalcitrance of the problems with healthcare access and equity.  But I believe the combined efforts of all the individuals working at the clinics and PCC, as well as the consistent and crucial support from Montgomery County, has made a massive difference for thousands of our fellow county residents and their families.  What I have done in the QHIC process is nothing in comparison to the work day-in and day-out by the leadership and staff of the McCares partner clinics.

With heavy hearts we mourn the passing of Arva Marshall Jackson who passed away on July 21, 2022.

Arva Marshall Jackson was one of the founding members of the Primary Care Coalition, joined the PCC Board in the early 2000s, and was active on the PCC Board until 2016. During her time on the Board, she served as Chair of the Board and later led the Selection and Development Committee. Notorious for her “wisdom and wise-cracks,” Arva was gifted at making people feel comfortable during difficult conversations and was able to guide a group through difficult conversations weaving in all perspectives and insights.

Arva’s passion, commitment, and concern for community was sparked in the early 1950’s when she became housemother for ‘Delinquent pre-adolescents’ who had been assigned there by the Juvenile Court of the State of Delaware. Since then, she focused her career on the premise that every life is worthy of the best the world has to offer—if you’re able and willing to work with others to realize it. After earning a Master of Social Work, Arva was recruited by the Children’s Bureau of Delaware, where she held increasingly senior roles. In 1968, she was chosen by the incoming Governor of Delaware, Russell W. Peterson, to join his administration where she served first as the Director for Urban Affairs and later as the Assistant for Human Affairs and a member of the Governor’s cabinet.

Arva moved to Montgomery County, Maryland in 1978, with her family, and in that same year was selected by the Director of the National Oceanic and Atmospheric Administration to become NOAA’s first Director for Civil Rights. In 1983, she was tapped to be Chief, User Affairs for the National Satellite, Data and Information Service and was recognized by NOAA for “outstanding excellence in promoting equality in NOAA’s workforce.” From 1986 to 1990, she was Acting Chief, Constituent Affairs at NOAA and served as the First Director of NOAA’s newly established Educational Affairs division from 1990 until her retirement in 1994.
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During her very active retirement, Arva continued to be a strong advocate in the community working for equity and children’s rights. She served on numerous nonprofit boards and worked tirelessly to advocate for community needs. In addition to serving on the PCC Board she was also an active board member of the Collaboration Council for Children Youth and Families, the Center for Adoption, Support and Education, the African American Health Program, and the Fetal Infant Mortality Review. In 2004, she was recognized by the Linkages to Learning program for “devoted efforts on behalf of Montgomery County’s children,” and in 2008 she received one of four Linowes Leadership Awards as an “Unsung Hero!” 

When Montgomery County began welcoming large numbers of unaccompanied minors from Central America, it quickly became apparent they needed more than resettlement. These children had been through incredibly challenging journeys and still faced many tough days. They had experienced trauma, and they needed complex, compassionate care.

The Primary Care Coalition and its partners initially had no mechanism to connect Care for Kids (CFK) participants with essential behavioral health services. But in 2017, PCC received a five-year grant from the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services to pilot behavioral health services for CFK participants through the Caring for the Whole Child (CWC) project.

CFK enrollment grew quickly during the five-year CWC pilot, from 4,800 to more than 7,000 children a year. When the program took in 794 new children in FY 21, 65.8% (523) were from the influx of unaccompanied minors, many of whom had experienced violence and trauma that no child should have to endure. CFK could not have addressed their behavioral health needs without the Caring for the Whole Child services.

The CWC project replicated a successful model for providing integrated behavioral health care among low-income, uninsured adults in Montgomery County. It was able to serve children with similar vulnerabilities by race/ethnicity, income, and immigration status. And it identified children and adolescents with unmet behavioral health needs; connected them to accessible, appropriate care; promoted collaboration among providers to improve the availability and delivery of services; and sought public and private support to maintain the program beyond the pilot.

With the CWC project, PCC partnered with four safety-net clinics that treat Care for Kids children: Catholic Charities Medical Clinic, CCI Health & Wellness Services, Holy Cross Health Center Germantown, and Mary’s Center for Maternal and Child Health. In the first year of program evaluation (April 2017-March 2018), these clinics served slightly more than a third (37%) of the Care for Kids participants. By March 2022, when the pilot ended, the clinics were serving three-quarters (75%) of the Care for Kids enrollees, and more than 400 children* had received over 1,400 behavioral health visits. Each clinic offered a medical home for well and sick care by pediatricians and other pediatric primary care providers. They also provided behavioral health services on-site staffed by licensed mental health professionals.

Now that the pilot program is over, PCC and our partners continue to serve children in need, independent of the HRSA funding. The CFK budget has included stable behavioral health services funding from Montgomery County since FY2019—covering counseling and psychotherapy for children and their families, as well as psychiatry visits and substance abuse treatment for patients who need the services. PCC has also generated interest among private foundations for additional support.

Despite the program’s success, it wasn’t without challenges. The routine screening and service connection processes were more complicated than expected. When PCC applied for HRSA funding, we anticipated overwhelming behavioral health needs waiting for a service opportunity. “If you build it, they will come,” in pop culture speak. There was minimal literature on the prevalence of behavioral health needs in pediatric populations. Still, it was clear that many Care for Kids participants had significant trauma exposure associated with behavioral health needs.

Yet CFK participants were slow to access behavioral health services, and it was clear we needed input from participating families for a more nuanced understanding of their behavioral health needs. Getting that input, however, was an ongoing challenge.

For insights, PCC began holding parent and teen advisory group sessions, complete with refreshments and stipends. Parent and teen sessions were held at the same place and time to minimize travel and time burdens. During the pandemic, PCC also experimented with virtual meetings that eliminated transportation. Whether held in person or virtually, participation in group meetings was inconsistent and often low. Care for Kids staff scheduled calls with individuals rather than groups for final participant input activities, and participation was relatively high: eight adolescents and seven adults. Although this model loses the ability for participants to build on each other’s comments, it may work better to include more participant voices.

Although process improvement and quality assurance are ongoing needs, they are hampered by data challenges. Providers generate a wealth of information in notes but comparatively few structured data points. Each clinic has its own electronic health records for the project with structured field capacity and documentation protocols. Simply mapping how information is entered and determining whether or not it represents extractable data took more than one grant year during the pilot project.

Despite the structural limitations, PCC’s partner behavioral health providers are passionate about this work. During the life of the grant, partner clinics received stipends for their participation in data collection and a quarterly learning collaborative. Participants opted to continue collaborating at the final meeting in March of 2022, even without funding support. They have committed to participating in ongoing quarterly meetings to share challenges and ideas for improvement and connections to other services.

That dedication is crucial because the pandemic uptick in behavioral health needs is real—at least in PCC’s patient population. The percentage of patients screening positive for depression doubled between 2021 and 2022, from 15% to 30%.  
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Ultimately, HRSA funding has spurred sustained investment in meeting children’s behavioral health needs, playing a foundational role in the availability of behavioral health services for children, many of whom have a history of trauma exposure. These services cannot erase the harm children have experienced, but they can help assure the brightest possible future for some of our newest neighbors.

*This figure is the sum of the unduplicated participants in each evaluation year. There may be some overcounting if participants received behavioral health services in more than one evaluation year. 
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This article has not been reviewed or approved by the Montgomery County Department of Health and Human Services. 

This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $650,000 with 62 percent financed with non-governmental sources. The contents are those of the author and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

How did you find out that you are Employee of the Year?
I was sipping my coffee early one morning, and our CEO (Leslie Graham) contacted me to let me know I had been selected as PCC's Employee of the Year. I couldn't believe it. I had no idea I was even being considered for the award. The last few years have come with both professional and personal challenges for many of us. There have definitely been some trying days for myself and my family, so having my work recognized during such a chaotic time feels amazing!

How long have you been at PCC?
I will be with PCC for ten years in December. I love my job. I feel beyond lucky to work with a core group of people who advocate and support me. I don't know if I'd be as successful in another organization. PCC is constantly offering opportunities to develop staff professionally, asking us what we need, and is a truly family-friendly workplace. That's meant the world to me. It's allowed me to raise my children and be there for them whenever they were sick or needed me, including when we lost their father to cancer at the beginning of COVID.

What led you to PCC in the first place?
When I heard about a job opening at PCC from a friend, I applied and didn't hear back. Then I applied again and didn't hear anything. I apparently wasn't making it through the recruiter screening because I didn't have any healthcare experience. So, I tracked down the hiring manager at PCC and made sure he received my resume directly. I really wanted the job and knew my experience was valuable, even if it wasn't in the healthcare field. Once the hiring manager saw my resume, he asked the recruiter to interview me, and I eventually got the job! That's why I always tell people to keep trying. Don't give up until you've done everything you can to get where you want to be.  

Where were you before?
I received my degree in healthcare administration during a recession when there weren't a lot of jobs available, and my searches were not going anywhere with only a degree and no experience in the field. I finally took a position with my family's law practice. Managing a multi-million-dollar law firm with six partners ended up being relevant experience because it prepared me to negotiate contracts and be an excellent advocate for clients, as well as honed my eye for detail.

Tell me about your work.
I work primarily to manage the billing and payments in support of PCC's contracts for specialty care, Cancer Crusade, and other State Cancer grants. One of my projects was working on a team implementing TriZetto, which offers electronic billing capabilities. Before COVID, everything was billed on paper. Although I had suggested going to an electronic claims processing system before, there was never money to do that – something those of us working in the safety net are all too familiar. But COVID changed everything. Suddenly, people were working from home, and the need to process invoices electronically became urgent. We finally got the funding and thumbs up. I was able to get the TriZetto system implemented so that PCC can pay doctors' offices in a timely manner, and doctors can invoice PCC from wherever they are, eliminating the need to rely on mail and paper claims.  

What do you find most rewarding at PCC?
The opportunity to work with a diverse immigrant population is what I find most rewarding about my work at PCC, especially in this day and age when immigration is used as a tool for division. I was raised by immigrant grandparents from Italy and grew up in Chevy Chase. My great-grandmother never learned English well, and as a child, adults in the community could be absolutely cruel. Forty years later, and unfortunately, some of the same sentiments and misinformation prevail. Giving back is rewarding, especially knowing programs like this didn't exist for families like mine in the not-so-distant past. Being a part of progression feels good!
It is also rewarding to know that we provide quality healthcare to people who have no other way to access it. Those of us with insurance sometimes have trouble scheduling appointments or finding care. The American healthcare system is not easily navigated. Can you imagine what it must be like to be without health insurance and try to get good care with little income? Especially with English often as a second language? PCC provides critical services to people who need them across multiple areas circumventing barriers that leave so many without care each year.   

What is most challenging about your work?
NOTHING moves quickly in the safety net, which can be frustrating. Finding ways to get things done with budgets that never seem big enough is always a challenge, as is not always having the staffing to make goals readily obtainable. COVID exacerbated all of this. Like many people, I woke up one morning, ushered my kids off to school, and rushed into work, not knowing it was my last day working in the office. The projects and plans I was working towards at work, my kids' sports, and our life as we knew it shut down. Many of our partner organizations temporarily closed, most lost staff, surgeries and appointments were being canceled, patients were not showing up for routine appointments, the grocery stores were empty, and I suddenly became a teacher to two high schoolers. Those first few months, I felt more like a participant in the Hunger Games than myself. I think the silver lining is all the resilience and grace I have learned. I am less hard on myself and others, I am driven to be more creative despite staffing and budget deficits, and while I haven't stopped thinking big, I have managed my expectations and learned to focus my energy in spaces it can flourish.  
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What are your interests? What drives you?
Outside of my love for PCC, which is pretty huge, my true passion is cooking and growing my own food! It is my hope that one day when I'm retired, I will be able to start my own business and buy a mobile pop-up kitchen that I can take into underserved communities in our area. I want to be able to teach people to grow their own food and cook healthy meals. The possibilities of what I can do and who I can serve with a business like this excite me. Redefining healthy eating and making cooking accessible are huge passions.  
My love of gardening is also very satisfying, and I regularly hike on weekends and kayak, paddleboard, fish, and jet ski at my family's bay house. However, my drive comes from being a Mom. My children have made me an infinitely better person and cultivated patience, empathy, and my desire to achieve. I enjoy watching them grow into adults, begin their kitchen endeavors, and develop their own passions. Of all the things I am thankful for, the privilege of being called Mom by them is number one!