In previous editions, we shared stories of people who took part in the Workforce Capacity Program and their journeys to pursue jobs in health care. In this issue, a program partner, Mr. Abdulaziz Kamus, Senior Clinical Manager at MCC Medical Clinic was interviewed and asked to share his thoughts of the program.

The Pulse:  What is your impression of the Workforce Capacity Program?

Mr. Kamus: The Workforce Capacity Program has been transformative for both participants and the community. It bridges the gap between untapped talent and workforce needs, providing participants with essential skills for entry-level healthcare positions. The program empowers individuals by offering training and opportunities for personal and professional growth, enabling them to take significant steps toward career stability.

The Pulse:  Is there any particular reason why the program has been so effective?

Mr. Kamus: The success of the program is the result of the fabulous partnership between the Primary Care Coalition, community organizations including Nexus hospitals, funders and motivated community members.  I have to say, the leadership and support provided by the Primary Care Coalition has been pivotal. They have been the critical link between the Department of Labor, partner organizations, Montgomery College, and the Nexus hospitals for the past year. Liza Greenberg’s tireless commitment to helping students navigate challenges—such as language barriers and passing certification exams like the pharmacy technician program—has been essential to the program’s success.

The Pulse: Who do you think might benefit from the program? 

Mr. Kamus:  This program is particularly beneficial for immigrants and newcomers, such as Afghan and Ethiopian community members, seeking meaningful employment in healthcare. It is also valuable for individuals looking to enter the workforce for the first time or those pursuing a new career.

The program also holds immense potential for former medical doctors who are unable to practice medicine in the U.S. By creating education programs that allow them to re-enter the healthcare field at an entry-level we can help them avoid underemployment and working dead-end jobs, enabling them to contribute meaningfully to their profession and community.

The Pulse:  What have you seen to be the challenges of students joining the clinic?

Mr. Kamus:  The clinic has seen a mix of successes and challenges as participants transition into our facility's roles. We hired three Afghan newcomers as medical and dental assistants. Their training at Montgomery College enabled them to step into these roles confidently, and they contributed meaningfully to our operations.

In addition, we hired a certified medication technician who was trained through PCC’s WSM (WorkSource Montgomery grant).  He is a former Afghan medical doctor who currently works in the pharmacy at the clinic and has already made significant contributions.
To further support participants, the clinic conducted mock interviews with Afghan and Ethiopian students to help them prepare for job interviews. These sessions boosted their confidence and equipped them with practical skills to succeed in the competitive job market.
However, challenges also arose. Two of the participants left the Clinic due to pregnancy and the demands of caring for their newborns, highlighting the need for more robust support systems for working parents. Another participant recently left for a better opportunity with a higher salary, reflecting both the competitive nature of the job market and the program's success in preparing individuals for upward mobility.

The Pulse:  What has been the impact on the community and partner organizations?

Mr. Kamus:  The program's impact on the community has been profound. It introduces a culturally diverse workforce into healthcare, fostering trust and improving care delivery, especially for underserved populations. Partner organizations like ours benefit by gaining skilled team members with unique insights and a deep commitment to patient care.

Our involvement in the Nexus Workforce Steering Committee, which includes four area hospitals, further enhances collaboration and strategic planning for workforce development. While the hospitals have been hiring entry-level healthcare students, many of them face challenges such as a lack of work experience and English language communication skills, which limit their job opportunities. Addressing these gaps is crucial for the program's long-term success.

The Pulse:  What does the future hold for the program?

Mr. Kamus:  Looking ahead, I envision an even greater impact for the Workforce Capacity Program. Given the high demand for this profession, we are exploring the inclusion of dental hygienist training in the curriculum. Expanding advanced certifications and leadership pathways could also retain talent and support participants' long-term career growth. Strengthening partnerships with community organizations to provide childcare solutions or mentorship programs could address some challenges participants face.

Ms. Liza Greenberg’s role in uniting key stakeholders, identifying barriers, and guiding participants toward success will continue to be instrumental in achieving these goals. Her dedication inspires confidence that the program can overcome any obstacle and grow even stronger.

​A grant from the U.S. Department of Labor(DOL)’s Employment and Training Administration funds 92.8% ($1.3 million) of the cost to train 200 healthcare workers and increase Montgomery College training capacity between December 2023 and November 2025. Non-governmental funds, including support from Maryland Physicians Care, support 7.2% ($101,615) of these costs. Additional workforce capacity efforts have been supported by WorkSource Montgomery, Maryland Physicians Care, and the Maryland Department of Labor.

​What happens when the way you self-identify is a taboo word? What do you do if the things you stand for make you a target? How do you escape when you’ve become your own worst enemy?

For this year’s storytellers—as for all of us—the answers are never simple, but they have a common thread: you’ll find them at Best-Kept Secrets, PCC’s 2024 Storytelling Show.

Sometimes, the best secrets are the ones we don’t keep.

This year’s cast of storytellers and secret-sharers includes:

Councilmember Gabe Albornoz, Chair of the Health & Human Services Committee
Nora Morales, Program Manager at Identity
César Palacios, Executive Director of Proyecto Salud
Edwin Rich, Co-Founder of Tree of Hope Association
Haseeb Shinwary, PCC’s Workforce Navigator Manager
Hillery Tsumba, PCC’s Chief Operating Officer

Join the Primary Care Coalition and our partners on Thursday, November 7th at the Silver Spring Civic Building for some of our very best secrets. We can’t wait to see you there.

Faith Ibura Ideki’s journey has taken her tens of thousands of miles, two continents, and almost five years. “Growing up in Nigeria, I dreamed of being a nurse.  I majored in Biochemistry in one of the Federal Universities of Technology in Nigeria with plans to join in the nursing program upon graduation. However, my husband’s career took us to Columbia, Missouri, where he accepted a position.  That changed everything.”  

​Faith had the good fortune to land a job at the University of Missouri hospital with duties supporting the nursing care team.  "I assisted with everything, including helping doctors, storing supplies, and providing patients with basic medical care."  I felt like I was helping people even though I wasn't a nurse.

When her husband was offered a new position in Washington, DC Faith and her family gathered their possessions, packed up, and relocated to Silver Spring, Maryland. "Because of my experience in Missouri, I had a better understanding of how to secure another position in health care," she explained. Unfortunately, despite her significant experience and excellent recommendations from past colleagues, she learned she would need certification if she wanted to be a part of clinical care teams in Maryland. And, as fate would have it, an informal conversation with a neighbor pointed her to an opportunity, putting everything back on track. 

"It was just a casual talk, and I mentioned to my friend that I was looking into getting the necessary certification. Here I was unemployed and looking for a way to become a nurse.   My friend told me that Montgomery College had a curriculum that was ideal for me, and that the Primary Care Coalition had a tuition assistance program.  Well, I applied to the program through PCC and was fortunate enough to be accepted as part of the second set of certified nursing assistant (CNA) students in the program. It was a blessing."

PCC’s Workforce Capacity program, a project of Nexus Montgomery, was created to meet hospital needs for entry-level healthcare workers and to provide career- path employment opportunities for diverse community members. The program is partnering with community organizations for outreach and student support, and scholarships provide community members with certification training at Montgomery College, designed as a first step into a healthcare career.  

After graduating from the CNA training program at Montgomery College in early October, Faith accepted an offer from Kensington Senior Living Center. By accepting the scholarship, she is committed to providing care in Montgomery County for a year. As Faith reflects on how far she has come, she says, "I understand that so much of what we achieve is because of the help of others. I wouldn't be where I am now if it hadn't been for the support from my husband and friends, as well as the significant boost provided by PCC.  I wish more people knew about it, since I know others are on the same path as me." 

"It took me a while,” she says, “but now finally I'm doing what I've always wanted to do: take care of people." 

Nexus Montgomery is a partnership of Montgomery County’s six hospitals and was created to improve health care quality and access in the county. 

A grant from the U.S. Department of Labor(DOL)’s Employment and Training Administration funds 92.8% ($1.3 million) of the cost to train 200 healthcare workers and increase Montgomery College training capacity between December 2023 and November 2025. Non-governmental funds, including support from Maryland Physicians Care, support 7.2% ($101,615) of these costs. Additional workforce capacity efforts have been supported by WorkSource Montgomery, Maryland Physicians Care, and the Maryland Department of Labor.

Marisol Ortiz is the Primary Care Coalition’s Director of Family Centered Care and—with 24 years of service—one of the organization’s most senior employees. She oversees the Care for Kids (CFK) program, ensuring PCC and partners meet healthcare needs for more than 6,000 children each year (CFK had more than 10,000 participants in FY24!). She coordinates with partners, listens to patient and community needs, anticipates immigration trends, coordinates with stakeholders, addresses program compliance issues and environmental impacts, and manages budgets, data, and reports.

“I love my job,” said Ortiz. “Working with children and families and giving them peace of mind by providing them with the health care they need impacts their lives in a meaningful way.” 

Ortiz was born and raised in Puerto Rico, where she still has family. After earning her political science degree, she came to this area for an internship with Univision’s Washington News Bureau. Ortiz found the news business exciting, but marriage and family soon took priority when she unexpectedly fell in love. She eventually found a job at PCC that suited her interests and skills and allowed her the flexibility she needed to raise her two sons and a daughter. 

“I have been able to use my skills here to help people,” said Ortiz. “I understand policy and how decisions are made, and I know how important it is to gather community input to fully understand the depth of the needs. I see the whole spectrum, so my degree and previous experience have helped me with my job.”
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“I want to be a voice of the community,” said Ortiz. “I want to ensure we implement programs and policies that really help people. Sometimes, programs and policies aren’t as successful as we want them to be because we haven’t listened deeply enough to what the community needs and how they want it and will use it. Making sure that that happens is what I like best about my work. It feels good to improve the health and lives of the people in the community.”

As an immigrant herself, Ortiz says she is driven to help others struggling to figure out life in a new country while overcoming a language barrier. She points to the powerful impact of services for children. She notes that a mother recently expressed gratitude for the behavioral health services that saved her daughter’s life. The ripple effect of those services likely saved the family, too, and impacted all those in the community who knew that child. 

“This is a good example of why it is so important to focus on children’s health needs,” said Ortiz. “There is a return on investment, and we can break the cycle and get where we need to be, with everyone healthy and well.”

Colleagues may not know that Marisol Ortiz is a self-proclaimed romantic who enjoys listening to music in her spare time and watching Netflix K-Dramas because they are beautiful. She also enjoys reading romantic novels. 

The Ortiz family also has a cat named Kaira, the featured Pet of the Month in the “Pets of PCC” section of the September Pulse. 

As a storyteller in PCC’s first Storytelling Show in 2019, Marisol’s story still lives online and in PCC’s FY19 Annual Report. Her colleagues will share new stories at this year’s “Best Kept Secrets Storytelling Show” event on November 7. The Storytelling Show is the Primary Care Coalition’s annual fundraising event supporting healthcare services for the community’s neediest residents. It is a good cause and one of the most enjoyable evenings around, leaving guests entertained and inspired. Buy a ticket today so you don’t miss out.

The Montgomery Cares (MCares) program provides access to comprehensive health services for more than 20,000 low-income, uninsured residents of Montgomery County each year and generally meets or exceeds national care quality benchmarks for Medicaid providers. Together, those data points indicate the program succeeds in helping nearly 2% of county residents stay healthy every year. But how do those outcomes compare to the level of need in the community? Are there gaps in our provider networks that leave out some of the very residents we aim to serve? To find out, the Montgomery County Department of Health and Human Services and the Primary Care Coalition (PCC) partnered with NORC at the University of Chicago to conduct a Montgomery Cares Network Adequacy study and report on the results.
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Those results [1] were largely positive, particularly in terms of the program’s reach. Of the estimated 25,775 Montgomery County residents potentially eligible for the program between 2021 and 2023, MCares actually served 23,539 of them—or 91% — with a caveat that results are based on census data and may undercount the potentially eligible population. It also generally met Maryland Medicaid network standards (15-minute drive, 10 mile distance), though the report noted a subset of patients (<15%) did not select the closest partner clinic as their medical home. The table below offers a comparison of MCares results to Medicaid time standards as reported in the final report.

​One challenge noted was for accessibility by public transit. When applying the Medicaid network standards to public transit routes, only 39% of participants had adequate access to any partner health center and even fewer (10%) had adequate access to their preferred health center. However, the report noted several clinic partners have existing programs to fund transport through ride share services. The accessibility results by car are positive: “Given the distribution of patients and health centers, it appears that participating health centers are well situated to serve both the current and eligible patient population.” However, the local public transportation infrastructure does not adequately support patients without access to a vehicle in timely transit to the safety-net clinics.   

However, there remain areas for improvement, particularly in access to specialty care, which faces substantially longer wait times than for primary care visits. Patients also noted that appointments during nontraditional operating hours would make access easier, though 58.8% of patients surveyed reported 9:00 am – 5:00 pm on weekdays as their desired appointment window. (Weekday mornings from 6:00 am – 8:00 am was the most popular window for nontraditional hours of operation, selected by 31.4%.) And 22% of patients surveyed responded that “more money to pay for visits and medicine” would improve access, despite the relatively low patient cost of MCares (there are no monthly premiums, and co-pays are capped at $35/visit for patients at or below 100% of the federal poverty level).

Other results of note, include:
- Participants most commonly reported using the hospital/ER as an alternative source for care, a result that underscores the importance of the healthcare safety net as an investment in hospital diversion. 
- The overwhelming majority of participants (71%) found the MCares program through their personal networks, rather than through formal outreach or referral programs. 
- The study also reported on predictive modeling of utilization over fiscal years (FY) 2025 and 2026 [2].  Results indicated the number of encounters will approach the budgeted 72,000 encounters for FY25 and grow to more than 74,000 in FY26. The degree of increase predicted for FY26 will increase program budget needs. 

Perhaps the most important takeaway: patient trust in our clinic partners is strong. “Patients widely shared that they trusted the medical advice offered by their providers and felt empowered to make decisions about their healthcare,” the accompanying Survey and Focus Group Summary [3] noted, “affirming that providers were easy to understand and explained concepts well.” 

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

End Notes
1.   NORC at the University of Chicago. Montgomery Cares Program (MCares) Network Adequacy Assessment: Final Report. May 2024. 
2.  NORC at the University of Chicago. Montgomery Cares Program (MCares) Patient and Encounter Projections for Fiscal Years (FYs) 2025 and 2026: Final Report. May 2024.
3.   NORC at the University of Chicago. Montgomery Cares Program (MCares) Network Adequacy Assessment Patient Voice: Survey + Focus Group Summary Final Report. May 2024.

The Montgomery Cares program (MCares) served 22,693 Montgomery County residents in fiscal year 2023, providing last-resort access to care for residents with incomes at or below 250% of the federal poverty level who do not qualify for state or federal healthcare access programs. Understanding the proportion of patients that maintain program participation year over year helps PCC and MCares program partners gauge how well we are meeting patient needs and where there might be areas for improvement.

We first explored overall trends in the data, which PCC data analysts extracted from MCares billing records for the fiscal years (FY) 2015-2023. The results show that while the overall number of patients participating in the program is largely steady, the individual patients participating in the program are not. Around 50% of individual patients stay with the program from one year to the next.

While the ideal is for every patient to have an annual primary care visit, we know that is not the reality for many adults—insured or not. Because MCares participation is defined by care usage, rather than by annual enrollment (as is the case in insurance participation), retention rates alone cannot tell us how many patients stop participating because they remain free of health concerns and how many stop participating because of access challenges.

To explore that question, PCC looked at participation according to the ICD-10 diagnoses included in billing documents (and verified in the electronic health record for the six clinic organizations that use a PCC-maintained system). PCC compared retention rates for patients with chronic conditions to those without a chronic condition from FY2020-2023. We found that 88.1% of patients who participated in each of those years had a chronic condition. Among patients who participated for a single year, only 44.6% had chronic conditions. When we looked at the number of chronic conditions among the most enduring patients, we found that 69.9% of four-year participants had three or more chronic conditions, versus 35.7% of one-year participants.

Combined, these results suggest that patients with more complex health needs are more likely to continuously participate in the program than patients with less complex needs, which makes intuitive sense. However, it does not tell us what happened to the patients with complex health needs who have limited program participation. That matters because these are the patients who need to be receiving care, and we want to know if they are. Studying data from the Chesapeake Regional Information System for our Patients (CRISP)—Maryland’s health information exchange—might help answer that question.

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

Elizabeth Arend Dutta joined the Primary Care Coalition (PCC) in 2017 and has made a significant impact during the past seven years, first as Director of Provider Services and most recently as the Director of Behavioral Health Program Design and Strategy for PCC.
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PCC’s annual Storytelling Show was Dutta’s brainchild; she helped facilitate the production of the first show in 2019. She even shared her own story on stage that year. The Storytelling Show has become a much-anticipated annual fundraising event that supports healthcare for the community’s neediest residents through a series of personal stories—each told in a heartwarming, funny, and inspirational way. The next Storytelling Show is on November 7th.

Born in New Jersey and raised outside of Boston, Massachusetts, Dutta has traveled extensively. After earning her master’s in public health, she worked in Ethiopia, South Africa, and Rwanda, before settling in Washington, DC. She now resides in DC’s Eastern Market neighborhood with her husband, Arin.

When asked what she liked best about working at PCC, Dutta said, “Being surrounded by mission-driven, passionate people who deeply care about the work is a joy. My supervisors over the years, the people I’ve supervised, senior leadership, they have all been so supportive. We care about each other as people. PCC is one of the most – if not the most – fulfilling jobs I’ve ever had--and I’ve had many!” 

As for her motivation and drive, Dutta admits that she started work at PCC in a political environment frightening to many of the people the organization serves. “My work reflects my values, and it was very motivating for me to know that I could go to work every day and make access to healthcare easier for the people who needed it,” said Dutta. 

“Also, for the last three years, my work has focused on behavioral health. Having experienced my own behavioral health crisis, I’ve got skin in this game. It motivates me to work to improve the Montgomery County behavioral health crisis response system because I see myself in that work. It’s very personal.”

Dutta graduated with her doctorate in health policy on August 31, so she hasn’t had much leisure time in recent years. But she does enjoy time with her newly adopted dog, Maggie, featured in the July issue of Pulse. She also loves any British TV show, including The Crown, Downton Abbey, and The Great British Baking Show.  

Many people don’t know that Elizabeth Dutta is a talented singer who took voice classes throughout high school and college. Her performance on the Kennedy Center’s Millennium Stage with her college chamber choir was a highlight. As her leisure time expands, Dutta may seek additional opportunities to perform. 

Unfortunately for PCC, Dutta is taking on a new role at George Washington University. Although it was a bittersweet decision, Dutta accepted a position as a research scientist for the Geiger Gibson Program in Community Health, starting October 1. She also teaches health policy to undergraduate public health majors at the university. Despite the career move, Elizabeth Dutta plans to stay connected to PCC and the people she holds dear. 

​For years, Tiffany took care of her ailing mother, providing her with the support she needed to live a comfortable life. This past May, Tiffany's mother passed suddenly, leaving her in a challenging situation. "Taking care of my mother was my full-time job," said Tiffany. "So, when she passed away, I not only lost the person I loved the most, but also my primary source of income, which was her. And on top of that, her landlord gave me two weeks to move out. So here I was: no mother, no job, and no home."

Ever resourceful, Tiffany was able to find a temporary solution by registering at the shelter at the IW Women’s Center at Crabbs Branch. It gave her somewhere to stay temporarily while she decided what to do next. "I wanted to carry on caring for people. Considering my background, I believed I could find a job in healthcare, but I discovered that I needed a certificate." 

And, as luck would have it, Tiffany learned about the PCC Workforce Capacity program. "I happened to learn about the PCC scholarship through a chance conversation with a friend. She told me to contact Liza Greenberg, Director of Workforce Capacity at PCC. I met with Liza, and she told me that I was eligible to receive support through the Workforce Development Program. She helped me complete the application. I was able to get a spot in the program with her assistance." 

In addition to Nexus Montgomery hospital partners and training institutions like Montgomery College, PCC’s Workforce Capacity program partners with community organizations that provide outreach, wraparound services, and student support. Through the program, Tiffany enrolled in the CNA program at Montgomery College. Everything appeared to be going smoothly until she had to relocate to a motel due to a fire that destroyed the shelter. "I was working part-time and attending classes, so my financial situation was precarious to begin with. Now that I was no longer able to live at the shelter and was forced into a motel, I couldn't afford to keep up with my studies and pay for my housing. I couldn’t believe the overwhelming situation I found myself in. I am a fighter by nature, but I needed an ally." 

Tiffany found allies among the PCC program staff as well as her professor at Montgomery College and the Montgomery College CNA program leadership. With Tiffany’s agreement and commitment to continuing, the team paused her initial enrollment and re-enrolled her for the next class. Thanks to her own tenacity and support from the PCC Workforce Capacity program, Tiffany is on now track to complete her CNA program in September. She highlights the lab and practical training as being especially beneficial. "I was able to perform CPR on a woman on a plane thanks to the training I received in the lab." After graduation, she wants to work in a hospital in Montgomery County. Tiffany remarks, "Sometimes when you think you’re all alone, if you stick with it and look around, there are angels there to help you." Tiffany’s journey illustrates how the Workforce Capacity Program – coupled the remarkable perseverance shown by candidates, is changing people’s lives. 

A grant from the U.S. Department of Labor(DOL)’s Employment and Training Administration funds 92.8% ($1.3 million) of the cost to train 200 healthcare workers and increase Montgomery College training capacity between December 2023 and November 2025. Non-governmental funds, including support from Maryland Physicians Care, support 7.2% ($101,615) of these costs. Additional workforce capacity efforts have been supported by WorkSource Montgomery and Maryland Physicians Care.

Mary Jane Joseph is a project manager for the Primary Care Coalition (PCC), overseeing cancer screening programs for our community’s most vulnerable residents. She serves uninsured individuals facing various challenges that make it difficult to seek and access healthcare. Joseph works hard to ensure that life-saving cancer screening is as easy as possible for everyone. She is also the chair of the Maryland Cancer Screening Workgroup, helping to spread the need for cancer screening and best practices across the state. 
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Giving “glory to the clinics” for their hard work in increasing colorectal cancer screening rates by as much as 50 percent under an initial one-year state grant that is now ongoing, Joseph notes that the clinics welcome all process improvement efforts and are committed to providing the best care to the patients they serve, despite being stretched in budget and staffing. Joseph is also proud of new efforts to offer all Montgomery Cares patients Cologuard test kits at no cost to detect colorectal cancer and for a partnership with Luminis Health that will provide 100 additional colonoscopies for patients in need. 

Joseph has worked for PCC for nearly 16 years and will celebrate her work anniversary in October. Her colleagues might be surprised to learn that she does not have a public health background. Before joining the organization, she had a long career in psychiatric nursing. She worked as a floor nurse, a residential treatment director, and Senior Director of Behavioral Health at Mid-Atlantic Medical Services (MAMSI), which transitioned to UnitedHealthcare while she was there. In that position, she was responsible for the quality of behavioral health care in Maryland, Virginia, Delaware, and North Carolina.

“I really missed spending time with patients, and at the time, I was on the Board of Governance for Adventist Behavioral Health; I knew they needed a position filled, so I went over there to become Director of Admissions and Residential Treatment and then Chief Nursing Officer,” said Joseph. The treatment facility was then known as Potomac Ridge Behavioral Health Center (now Adventist HealthCare Shady Grove Medical Center - Mental Health).

“When I left there, I took a break to spend time with my grandchildren, and I was enjoying myself because we were going on field trips, having sleepovers, and going to the pool, and having a great time,” said Joseph. “My husband was like, are you going back to work?” 

Joseph admits that she “works because she likes to work.”

“I’d seen this job at PCC, and they wanted someone to start patient navigation. Since I had started a patient care management system in psych, I knew I could transfer my skills. My first assignment when I got the job was to develop patient navigation here in the clinics. All of the clinics now have some form of patient navigation,” said Joseph. 

“Helping people” is what Mary Jane Joseph loves most about her job, and she is driven by her passion to make healthcare and cancer screenings equally—and easily—accessible to everyone. 

“Uninsured patients should be treated the same as insured patients when it comes to testing so that they don’t have to worry about getting that done,” said Joseph. “We need to make the testing as easy as possible since many of these patients still have other barriers to overcome, like transportation, time off from work, and childcare.”

She points out that patient outcomes are better when cancer is caught early through preventive screenings. Regular mammograms can detect breast cancer at the earliest stages. FIT and Cologuard testing, as well as colonoscopies, can detect colorectal cancer early. Hospitals also benefit from preventive screenings because early detection diverts patients from ending up in their emergency rooms with severe, undiagnosed symptoms and late-stage diseases that are harder to treat. 

Joseph also connected the University of Maryland School of Nursing with the Montgomery County safety-net clinics to provide a community health clinical experience for nursing students. As a clinical instructor, she wanted to provide students with insight into the difficulties of community health nursing. Joseph continues to work with nursing students who want to volunteer in the clinics. 

One little-known fact about Mary Jane Joseph is that “Mary Jane” is her first name, and she has no middle name. “Mary” is what most people call her. She was named “Mary” after her father’s mother and “Jane” after her mother’s mother, and she grew up with each of those families calling her either “Mary” or “Janie.”  Her husband calls her “Mary Jane” when he’s annoyed. 

Mary Jane Joseph and her husband live with their three-year-old rescue cat, Boogie, who is the master of the house. She is close with her family, which includes a grown son and daughter and four grandchildren (three boys and a girl). The youngest grandson has graduated from high school, and the oldest has a six-month-old daughter, making Joseph a great-grandmother. 

“We have a condo at the beach, I can travel when I want to, and I do a lot with my church and am involved with my faith,” said Joseph. “I am very content.” 

With a love of travel, a trip through New England is part of Mary Jane Joseph’s plans for this fall. 

Despite having some of Maryland’s best health outcomes and a comprehensive set of community resources available to its residents, Montgomery County has many disparities across its 81 ZIP codes. To address some of them, the Nexus Connect Program piloted pathways to community resources in a hyper-targeted region of the County: ZIP codes 20877 (Gaithersburg) and 20886 (Montgomery Village). 

PCC and our partners strove to connect 1,000 residents of the area to resources within their immediate community over the two-year initiative. By June 2024, we had done just that.

Program Structure
With grant funding from the Maryland Community Health Resources Commission (CHRC)*, the program focused on five main pillars of access to address social determinants of health impacting community members: access to primary care, health education & disease management, food insecurity, financial assistance, and early childhood education. 

• Initial outreach: PCC partnered with Cross Community to conduct outreach within the service area and participate in large community events where their Justice, Equity, Diversity, and Inclusion (JEDI) staff would conduct social determinants of health (SDOH) screenings.  In the second year, HealthPro health promoters were brought onboard to increase program reach and screen additional residents across both zip codes. 
• Assistance with food and daily needs: Gaithersburg Help, a local organization focused on addressing basic needs, provided access to their food pantry in addition to infant care, daily use items, and prescription assistance. Cross Community also provided regular food and diaper distributions.
• Tools for healthy development: The Montgomery County Collaboration Council for Children, Youth, and Families (MCCC) provided The Basics program, an early childhood education resource for parents of children under five. 
• Financial help via tax-prep support: Cross Community also ran an annual Volunteer Income Tax Assistance (VITA) clinic, which offers free tax preparation services to low-income residents, as well as those who are elderly, disabled, or may have limited English proficiency. As the County VITA information notes, there are state, federal, and local tax credits available for residents below a household income threshold, as well as credits based on dependent children, occupation, and living situation. 
• Health management and care navigation: Holy Cross Health community health workers (CHWs) facilitated follow-up navigation for any program participant in need of connection to primary care services, health insurance, or health education.
• Implementation oversight: The Nexus Montgomery Regional Partnership (NMRP)—a collaborative of the hospital systems in Montgomery County focused on lowering total cost of care and positively impacting population health across the region—monitored program progress.

Key findings
The majority of community members screened were living at or below 200% of the federal poverty line—pegged at $62,400 in 2024 for a family of four—and faced challenges accessing healthcare and meeting social needs. By June 2024, over 170 parents were enrolled in The Basics program, and Cross Community had supported 50 families with their taxes. Over 400 participants had received food services, and another 270 had been connected to diapers, formula, and other daily-use items. 

Over 300 participants screened positive for either prediabetes or hypertension and over half of these participants were enrolled in health education and chronic disease management programs at Holy Cross Health, such as Road to Health and the Diabetes Prevention Program (DPP). 

At the time of screening, well over half of all Nexus Connect participants reported that they did not have a primary care provider or health insurance coverage. The program was designed to make an immediate connection to primary care at the Gaithersburg safety-net clinic that offers preventive check-ups, connection to specialty care, and medical coverage for those deemed uninsurable. 

A potential success of the Nexus Connect program was its grouping of affordable health and preventive care access within a package of basic needs, and its leveraging of hospital partnership data to assess impact. While the total cost per person screened was less than $375, the ability to measure changes in potentially avoidable emergency department utilization over time allows PCC to estimate a return on that community investment. Final evaluation on this measure is still pending because of the lag in hospital data availability through the Chesapeake Regional Information System for our Patients (CRISP). As of December 2023—three-quarters of the way through the pilot—non-emergency hospital use had declined by 11.55% from baseline in six high-need census tracts within the target ZIP codes.

The Takeaway
The Nexus Connect program demonstrated a model for SDOH screenings and tailored social services for underserved communities in Montgomery County. PCC strives to ensure that all residents have equitable access to healthcare and social resources that will allow them and their families to thrive. Ensuring that access requires cross-sector partnerships and benefits from groundwork by community health workers; both elements need more systematic support. 

*Supported by the Maryland Community Health Resources Commission. The views presented here are those of the author and not necessarily those of the Commission, its Commissioners, or its staff.