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.