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!