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!

col·lab·o·ra·tion, noun, the act of working together to complete a goal

Collaboration is how the Primary Care Coalition and its partners have achieved so many shared goals over the years in Montgomery County. It seems like a simple process, "You do what you do. I'll do what I do. We'll do amazing things together!"

​But things are rarely that simple. Although collaboration is magic when everything goes smoothly, it often takes experience, practice, and a concerted effort to get it right. That includes an intentional long-term investment of time, resources, and considerable emotional energy to continuously involve partners in every aspect of vision, design, and operations.

I want to share three things we've learned here at the Primary Care Coalition that can tip the balance and derail even the most well-intentioned efforts. A little awareness can make a difference in finding the magic and ensuring collaborative success.
 
Politeness… but not too much. I may be pointing out the obvious, but establishing and maintaining trust with current and potential collaborators is essential, so avoid being too polite to discuss differences of opinion. Collaborative organizations must have a culture of transparency and reliability, where disagreements are openly discussed and resolved so that everyone can get on the same page.
 
Progress… but not too fast. Keeping the collaborative momentum moving may seem efficient, but it limits the time available for leaders to have meaningful conversations. And that can lead to people feeling left out and undervalued when their concerns are overlooked. Don't let anyone lose faith in the process because there's no time to address conflict. Be sure to address any issues along the way.
 
Perfectionism… but not too focused. To "set a clear vision," leaders might be tempted to roll out a proposal or solid solution before seeking broad input from partners and stakeholders. Don't risk alienating your collaborators by failing to seek their input first. Take the time to hear what they have to say before developing a proposal or coming up with a solid solution.
 
The Primary Care Coalition has nearly 30 years of experience providing quality health care to Montgomery County's most vulnerable residents. Thanks to our many successful partnerships with clinics, hospitals, healthcare providers, and other community groups, all of whom have brought the right amount of politeness, progress, and perfectionism to our collaborative efforts, we know that we can achieve so much more together than we can individually. That's the magic of collaboration!

Facing healthcare workforce information that is scattered and frequently out of data, the state of Maryland recently selected the Primary Care Coalition (PCC) to develop the blueprint for a new statewide information approach. The planned Maryland Healthcare Workforce Data Clearinghouse will provide information on physicians and other healthcare workers in real-time. Access to this information means the state department of health and other stakeholders can better deploy licensed healthcare workers to the communities that need them. And by adding critical characteristics like the languages providers speak, it will also open new opportunities to match providers based not only on patient numbers but on their cultural needs.

"We consider this to be another one of our exciting Primed by PCC Health Force projects that will change the face of healthcare in our community and across the country," said Project Director Shawnda Sullivan. "We are excited at the opportunity to develop a blueprint for an accurate and responsive workforce database that will ensure Maryland residents have access to the physicians and and other healthcare providers who meet their specific needs for quality health care." Sullivan is PCC’s director for community physician engagement.

The data clearinghouse will be organized across provider types, disciplines, and settings, allowing the state to better address health disparities among populations at high risk of poor health outcomes and the medically underserved, including racial and ethnic minority populations and rural communities. The need for the clearinghouse is critical considering the pandemic's impact on the healthcare workforce. 
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The Maryland Department of Health selected PCC to develop this blueprint with funding from the National Initiative to Address COVID-19 Health Disparities Among Populations at High-Risk and Underserved, including Racial and Ethnic Minority Populations and Rural Communities and the MDH Office of Population Health Improvement.  

​PCC has a history of developing and implementing successful IT projects that improve communication among healthcare organizations. Those projects include building and deploying CHLCare—an open-source, web-based electronic medical record that created a more integrated system of care among independent safety-net clinics—and leading the partnership to develop MeDHIX—an early effort to share patient information among hospitals and safety-net clinics serving uninsured patients in the Greater Washington region.

In addition, PCC continues to manage large population health programs within the community, such as the Nexus Montgomery Regional Partnership. During the pandemic, PCC’s Nexus Montgomery and Population Health team used the existing Skilled Nursing Facility (SNF) Alliance for quality improvement to build dashboards on SNF bed availability. These dashboards helped Nexus Montgomery partner hospitals manage their surge capacity by discharging COVID-positive patients who needed less acute care to SNFs with the necessary isolation areas and PPE stockpiles to care for them.

In addition to Sullivan, who provides project leadership and serves as the primary point of engagement for stakeholders, the PCC staff working on the project are Mindy Pierce, senior director of Nexus Montgomery and Population Health, Fareed Anjum, director, Data and Informatics, and Thomas Lewis, M.D., chief information officer, who will provide technical leadership, oversight, and guidance.

The project involves assessing existing models and mapping the information ecosystem to determine what kinds of data currently exist and how it is stored for future sharing. It also includes designing the technical capabilities and cost estimates for a future system to collect, store, and share current healthcare workforce data. With the clearinghouse in place, the state can identify and address healthcare workforce gaps to improve population health and health equity.

The project started in April with a review of current clearinghouse models and will continue through 2022. 

by Leslie Graham
President and CEO, Primary Care Coalition

​For the past two years, we’ve been singing the praises of essential front-line workers who put themselves in harm’s way so the rest of us could stay safe during the pandemic. Thousands became ill or died in the line of duty. Caring for us. Providing for us. Serving us. They are true heroes. 

​Unlike their fictional counterparts -- Superman, who works for free, and Bruce Wayne, who is independently wealthy – few, if any, of our front-line workers could afford to put their lives on the line for less than a living wage, yet many of them did. That’s why it’s so critical now that we adequately compensate our health and social services heroes. There’s no excuse to do otherwise.  
 
Recognizing this, the Montgomery County Executive proposed a 6% inflationary increase to nonprofit contracts for the upcoming fiscal year. This is most welcomed and appreciated. Yet, this increase doesn’t keep up with inflation, currently at 8.5% and still on the rise. PCC and our partners are advocating for a 10% increase in nonprofit contracts and a 20% increase in health safety-net organizations that have been hard hit by the pandemic. We hope you will join us in this request to the County Council.
 
In Maryland, community-based health and social services nonprofits employ 182,000 workers.[1] It is a predominantly women-led sector. The percentage of nonprofit executive directors who are female is 71%, and 31% are people of color.[2] Prior to the pandemic, there was a lack of understanding of the important role these organizations play, which may explain why nonprofits are often financially stressed.[3]  The largest source of revenue for nonprofits in Maryland is government funding[4]. However, this often does not cover the full cost of providing the services, restricts how that funding can be best used and precludes building financial reserves to address critical challenges. 
 
The last two years have proven that community resilience depends on nonprofit organizations and their employees. Despite being underpaid and underappreciated before the pandemic, nonprofit workers still managed to step up when the crisis hit. They provided health services, emergency food, and rental assistance while continuing their pre-pandemic missions of supporting children and families, caring for people with disabilities and the elderly, and providing services to the economically disadvantaged. But two years in, with rising inflation, burnout from traumatic work conditions, and competition from higher-paying private employers, nonprofits are struggling to find and retain staff. 
 
Reversing that struggle is dependent upon paying these heroes fairly for the work that they do consistently and with deep caring to meet the health and social services needs of residents. 
 
Please show your support for our front-line heroes by asking the County Council to support the requested increases for nonprofits and safety-net healthcare providers.  
________________

1. Maryland Nonprofits by the Numbers, November 2021
2. Maryland Nonprofits Covid-19 Pandemic and Racial Equity Survey, November 2021
3. Alliance One “A National Imperative: Joining Forces to Strengthen Human Services in America” 2018
4. Ibid, Maryland Nonprofits Covid-19 Survey, November 2021

by Annice Cody
​Chair, Board of Managers, Nexus Montgomery Regional Partnership
President, Holy Cross Health Network, Holy Cross Health

In a symphony, the beauty of the music depends upon the collaboration of every musician. Few people recognize the symphony of care that goes into every delicately orchestrated hospital and nursing home stay. Just like in an orchestra, all of the players - physicians and nurses and supporting roles like lab technicians, certified nursing assistants, and pharmacy technicians - shape the overall tone and quality of a patient's experience. It is fundamentally an ensemble affair, and our local facilities are struggling to fill key supporting roles.
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The healthcare field not only needs more workers, we also need diversity. Among Montgomery County residents, there is no racial or ethnic majority population. As health care organizations, we need a workforce that reflects the racial, ethnic, cultural, and linguistic diversity of our patients, who can communicate in patients' languages and provide culturally appropriate care. 
 
At the same time, many of our communities need greater employment opportunities. Large numbers of people lost service or hospitality jobs in the pandemic, and many of those jobs have not returned. Healthcare is a growing field with a wide range of opportunities for entry-level jobs and advancement. With the necessary training, there are ready career opportunities in healthcare professions. But many people do not know the resources available to help them access secure employment and a brighter future.
 
That is why Nexus Montgomery Regional Partnership, Montgomery College, and the Primary Care Coalition have developed a collaborative approach to workforce development.
Our program will: 

• Expand the pipeline of culturally and linguistically diverse students new to the workforce, ensuring that the healthcare workforce mirrors the community and supports economic empowerment for under-employed residents.
• Increase the number of students who can be served in Montgomery College's high-quality health care programs.
• Ensure that students have the wrap-around services needed to overcome barriers to education and employment success. 

 
Nexus Montgomery Regional Partnership (Nexus Montgomery) is a joint venture among the six hospitals operating in Montgomery County to identify and jointly act on needs in their shared community. As the Nexus Montgomery management entity, the Primary Care Coalition has requested federal funds to support the entire training pathway, from program recruitment to job placement and career planning. The program will assist up to 200 low-income healthcare trainees from underserved areas in Montgomery County to access, pay for, and complete Montgomery College's degree and certificate programs.  
 
Our plan is for this program to create a sustainable pipeline of students entering health careers, to meet the ever-growing demand for more workers. By providing assistance with getting started in the field, we hope to establish pathways toward long-lasting career growth and success. We will have created a win for healthcare systems and our community—exactly the results our Nexus Montgomery partnership is all about.  

The Pan Asian Volunteer Health Clinic -- part of the Montgomery Cares group of community health clinics -- has been a staple in promoting critical and culturally-specific care for the Asian community since 2003. When the COVID-19 pandemic hit, the volunteer physicians, pharmacists, and registered nurses [RNs] – mostly Chinese speaking -- kept the clinics running and quickly adapted so that they could offer testing. As the calendar turned to 2021, they pivoted to the difficult task of vaccinating their community.

Kate Lu, the Chinese Culture and Community Service Center [CCACC] Health Center Director, led PAVHC team and thus far, they have served more than 1000 community members with about 1800 shots. They help community members overcome language and technical barriers in accessing vital health care.

“We aim at serving the hard-to-reach populations such as the Montgomery Cares groups and undocumented people we normally don’t see. That means a lot of hard work from our staff and volunteers. But we are all happy with what we can do for the community. COVID-19 has helped us grow and to fulfill the things we had been dreaming about to do for years, that is, connecting the underserved to healthcare," Lu said.

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We're pleased to announce the latest innovation from Nexus Montgomery in the push to minimize the number of Montgomery County residents who have diabetes and increase the resources available in the community including boosting education about diabetes prevention and self-management for those who suffer from diabetes.

The Diabetes Educators' Learning Collaborative [DELC] is part of a five-year program that aims to significantly improve diabetes education and prevent new cases of diabetes in Montgomery County – funded by a Health Service Cost Review Commission Catalyst Grant.

Set to launch in early May 2021, the Learning Collaborative offers a home for diabetes education providers and lifestyle coaches to share challenges, resources, and best practices for how to improve the programs they run. Those programs: the Diabetes Prevention Program [DPP] aimed at high-risk individuals who don’t yet have the disease and Diabetes Self-Management Education [DSME] designed for individuals who already have diabetes.

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