This personal journey ultimately led Anna to change career paths. Her first role in the field was as a Care Coordinator for Care for Kids, where she began in 2011. Later, encouraged by Marisol Ortiz, Primary Care Coalition’s Director of Family Centered Care, she transitioned to working with adults through Project Access, beginning that work in 2012.   

Project Access is a specialty care referral network administered by PCC. The program is supported by a committed group of health care specialists, local hospitals, and diagnostic partners who work together to ensure that low-income, uninsured community members receive access to essential specialty services. “We often work with individuals who clearly need help but don’t always know how to navigate the system—or fully understand the seriousness of their situation,” explains Ana. 

Ana views her work as both meaningful and deeply personal. “It’s a great feeling when you’re able to help someone—whether through guidance, encouragement, or connecting them to the right services. I believe we all have space in our hearts to help others. For me, my career has become a passion because of that belief.”  All this is very much in keeping with her Salvadoran roots. “As a Salvadoran, I was raised with a deep sense of community and strong family values, and it’s natural for us to come together and support one another in times of need,” Ana adds. 

A mother of five, Ana is proud that all of her children have chosen careers related to helping others as well, following in her footsteps. Outside of work, she enjoys singing and dancing—not professionally, but purely for the joy of it—reflecting her free-spirited nature and love of life. As a native of the D.C. area who grew up here, she also finds fulfillment in knowing that her work gives back to the community she has always called home. 

The Skilled Nursing Facility (SNF) Alliance continues to be a cornerstone of collaborative care across our region, bringing hospitals, skilled nursing facilities, and community partners together around one shared goal: better outcomes for patients transitioning between care settings. 

At its core, the SNF Alliance is focused on strengthening communication, coordination, and accountability between care teams. These efforts are especially critical for patients who are at higher risk for complications, readmissions, or setbacks during recovery. By improving how they share information and align care plans across settings, the Alliance aims to reduce avoidable readmissions, prevent errors, and support smoother, safer transitions for patients and families. “When everyone is on the same page—from the hospital to the SNF—the difference for patients is immediate. The Alliance helps us support safer transitions and better outcomes when patients need it most,” points out Juhi Morrison, PCC Clinical Director, Programs. 

What Good Care Transitions Look Like 

Through the Alliance, SNFs and hospital partners have identified several practices that make care transitions more effective. These include ensuring accurate and timely transfer of clinical information, establishing clear and actionable care plans, and holding brief touchpoint meetings between hospital and SNF representatives prior to a patient’s transfer. Whenever possible, these conversations also include patients and families, helping ensure everyone understands the plan of care and what to expect next. Equally important is a shared understanding of the specialties, services, and capabilities available across our SNF partners. “By helping hospital and SNF teams connect early and share clear, consistent information, PCC plays a key role in keeping care transitions coordinated. That alignment helps patients and families feel supported and allows care teams to focus on a smoother, safer transition,” Morrison notes. 

New Area of Focus: Care Transitions and Complex Patient Handoffs 

This year, the SNF Alliance has named care transitions and complex patient handoffs as a dedicated workgroup area of focus. (A “care handoff” refers to the transfer of responsibility for a patient from one care team to another—such as from a hospital team to a skilled nursing facility.) When these handoffs are complex, involving multiple conditions, medications, or social needs, the risk for miscommunication increases. Because this is a newly selected focus area, Alliance members are actively working together to define clear goals, determine how progress will be measured, and establish a shared vision of what success looks like. This collaborative approach ensures that improvements are meaningful, measurable, and grounded in the real-world experiences of care teams across settings. 

Expanding Beyond Hospitals and SNFs 

​In addition to hospital and SNF collaboration, the Alliance actively engages community stakeholders to broaden the support available to patients. These partnerships enhance both clinical and operational efforts, helping address social needs, streamline processes, and strengthen the overall safety net for our community. “By partnering with community organizations, we’re able to support patients beyond the walls of our facilities. These relationships help us address social needs, reduce barriers to care, and ensure patients have the support they need for a safer, more successful recovery,” sums up Morrison. 

As care continues to grow more complex, the Skilled Nursing Facility Alliance remains a powerful example of what can be achieved through shared accountability, open communication, and a commitment to continuous improvement. Together, we are building a more connected system of care—one transition at a time. 

Kristine also played a critical role in supporting the Finance and Health Care Access teams. She audited and identified outstanding accounts receivable, tracked corrected invoices for the Maryland Cancer Fund, and worked closely with Maryland Department of Health staff to strengthen relationships and safeguard critical funding streams. During the vacancy of the Senior Program Manager for Montgomery Cares, Kristine seamlessly backfilled responsibilities, ensuring uninterrupted services while maintaining her own workload. She also led the design and implementation of PCC’s site audit process, conducting audits and helping train the incoming Senior Program Manager. 

Known for her positivity, reliability, and commitment to excellence, Kristine consistently strengthens PCC’s internal operations while ultimately improving the experience of providers and patients we serve. “Kristine brings exceptional integrity, care, and leadership to every aspect of her work. Her ability to step in wherever she is needed—while still elevating the quality of our systems and services—embodies the very best of PCC’s mission. We are deeply grateful for her contributions and proud to honor her as our Employee of the Year,” related PCC President Annice Cody. 

Reflecting on the recognition, Kristine expressed her gratitude and appreciation for her colleagues, sharing: “I am very grateful for this recognition, and I know none of it would be possible without my PCC colleagues. This work is truly a team effort, and I am thankful every day to be part of an organization where collaboration, support, and a shared commitment to our mission are so deeply valued.” 

Beyond her role at PCC, Kristine is deeply engaged in community leadership. She mentors emerging leaders through the Healthcare Council’s Young Leaders Mentorship Program and joined the Board of Directors of the Society for Orphaned Armenian Relief (SOAR), Baltimore Chapter, in March 2026. Committed to continuous professional growth, she also participated in the Leadership Montgomery CORE Program 2025, where she was selected as part of a competitive cohort of senior executives from the public, private, and nonprofit sectors. Through the program, she developed a strong understanding of Montgomery County governance and built lasting relationships with county and cross-sector leaders to strengthen her leadership and community impact. 

Please join us in congratulating Kristine on this well-deserved recognition and thanking her for the lasting impact she continues to make at PCC. 

Community Reach of Montgomery County has served Rockville and Montgomery County since 1967 with a vision of a collaborative community where basic resources and opportunities are accessible to all. A core resource that was missing for many residents: access to high-quality, culturally-competent health care. In the early 2000s, Community Reach began offering mobile health services, and in 2009 opened the Mansfield Kaseman Health Clinic (MKHC). 

MKHC is a partner health center in the Montgomery Cares network, serving 1,013 patients in 2,281 visits in fiscal year 2025 (FY25). The MKHC’s fiscal year 2026 (FY26) strategic plan aims to serve even more, with a target of increasing their average monthly visits from 180 to 275. To do that, they have combined increased community outreach with increased clinic capacity. Filling an open nurse practitioner position increased their average monthly visits from 200 in the first quarter of FY26 to 241 in the second. 

The clinic also offers a number of specialty care services for MCares patients through its roster of volunteer providers. A new volunteer physical therapist has also been in high demand, and the clinic recently added a volunteer endocrinologist to support patients with conditions like diabetes or thyroid disorders. 

Besides adding service capacity, MKHC is working on improving existing processes and making data-informed decisions about new strategies. A team of staff and volunteers are pursuing systematic community outreach opportunities, and they have set up a tracking system to identify the most impactful efforts. MKHC has simplified their patient satisfaction survey in hopes of getting feedback from more patients, and a student working toward a master’s degree in public health is helping the team identify opportunities for process improvement.

There are many areas of growth to celebrate, but MKHC has also seen negative impacts from recent political changes. Clinic staff have noted that some patients have moved out of the area; others have had a reduction in employment making it more difficult to take time off for appointments or pay co-pays if they are not working as much, some patients are too scared to leave home or use public transportation. Federal job cuts also affected two of MKHC’s volunteer primary care providers, ending their ability to donate time at the clinic. “We continue to adapt our strategies to address these challenges,” says Executive Director Sarah Basehart, “and remain committed to improving access and care for our community.”

Together Community Reach and its subsidiary MKHC offer a range of services to patients and community members, from English learning through the Language Outreach Program to permanent supportive housing, eviction prevention and in-home support for seniors. This May, they’ll celebrate both organizations at the Woven Together Gala. “Reach’s work began generations ago with a small group of like-minded individuals,” explains Basehart. “Over time, we have woven in new pieces and new connections, growing into a closely-knit network of services, individuals, and organizations working to empower our entire community.”

Montgomery Cares (MCares) is one of PCCs legacy programs that has served residents since 2005. This program operates as a coordinated network that brings different primary care medical providers under one connected health care model. Today, MCares partners with 12 health center organizations and the Montgomery County Department of Health and Human Services, collectively serving nearly 25,000 adults annually. 

Through Montgomery Cares, uninsured residents have access to a network of providers that include primary care, behavioral health services, specialty care, dental care, and medication.  

We have completed reporting on the first half of this fiscal year, and we are excited to share program progress.  

Montgomery Cares Behavioral Health Program Challenges & Opportunities 

Our Montgomery Cares Behavioral Health Program (MCBHP) utilizes the evidence-based Collaborative Care Model across nine health centers in the county. Through closer collaboration with PCC’s population health team, our behavioral health program is strengthening linkages to disability and social services, improving post-discharge support for uninsured individuals.  

Given heightened stress within the communities that our immigrant neighbors live and work in, our behavioral health team is also finding new avenues to support patient mental health. We are actively working to address increased anxiety and fear related to immigration status, reduced service utilization, and family strain resulting from detainments. These external pressures have significantly impacted patient mental health and engagement in care, and the program continues to explore innovative approaches to support affected residents. As shown in the graph below, our behavioral health team noted a trend where more unique patients are receiving behavioral health services this fiscal year compared to the same period in FY25. 

While adjusting to more patients being seen, the team is also experiencing staffing shortages and anticipate increases in psychiatry hourly rates, both of which pose risks to timely access and service capacity without additional funding 
Due to the increase in need for a bilingual mental health workforce, MCBHP is actively working on strengthening academic partnerships to grow the behavioral health pipeline. Schools of social work place students with agencies for 1-year internships. These internships allow master of social work students to gain real-world experiences serving patients. Now, more than ever, we need a workforce interested and equipped at serving uninsured patients who face also face economic and cultural, and linguistic challenges when accessing care in traditional healthcare environments.

Specialty Care Improvement Focus Areas  

Project Access has experienced some recent changes, including the loss of two specialty providers in Oncology and Renal Care. While this affected access in the short term, it also created an opportunity to rethink how we engage with providers and strengthen collaboration moving forward. 

Recent surveys and interviews with specialists found that providers felt connected to our mission and 85% were satisfied or very satisfied participation in Project Access. Yet, they also shared that moving forward they would value greater connection with our PCC team managing specialty care. As a result, one priority in quarter two included developing more structured provider engagement plans to nurture strong partnerships with specialists. 

Our team also has spent a significant amount of time understanding how to improve care coordination and maximize timely care. To streamline workflows and boost efficiency, PCC is implementing a new case management system. There will also be a strong focus on ensuring primary care providers receive specialty care consult notes from specialists so they can follow up with their patients after they’ve been seen. Further details of the improvement project can be found in February’s Pulse, and key lessons learned from this project can be found in our recently released edition of Brainwaves. 

Efforts are also underway to expand the Specialty Care Network. We’ve identified high-need specialties and are prioritizing recruitment in Dermatology, Ear Nose and Throat, Hematology, and Oncology. Outreach is already in progress, marking an important step toward improving access and meeting patient needs. 

​As shown in the chart below, FY26 is showing stronger growth in unique patients compared to FY25, with the program reaching more people earlier in the year. By December, we provided 1,093 appointments, a nearly 25% more than last year, reflecting expanded access for patients utilizing Project Access services.  

Return On Investment 

Across the MCares services, we have seen a consistently strong Q2 return on investment (ROI) driven by prevention, care coordination, and leveraged partnerships. Primary care alone has turned an investment of $4,534,460 in 39,997 patient encounters into care valued at $9,999,250.  

Individual service areas offer additional examples of investment impact. The Medbank program delivered $2.4 million in no‑cost medications, easing financial strain and supporting chronic disease management for just over 1,100 active patients at a cost of $203,000. Similarly, Cancer Prevention efforts, such as free Cologuard kits negotiated with Exact Sciences, increased screening rates at a lower screening cost while avoiding higher downstream treatment costs. Together, these examples show how MCares turns strategic infrastructure investments into high-impact outcomes. 

​Overall, Q2 results show that MCares ROI is also reflected in real patient impact—more people accessing care earlier, navigating services more smoothly, and receiving support during a challenging time. These results reinforce MCares’ role as a reliable safety net for uninsured residents. 

In November, the Primary Care Coalition (PCC), the Health Centers Leadership Council, and the Montgomery Cares Advisory Board made a joint request to the County Executive to fund $9.9 million in critical needs for FY27. These requests were not based on projected demand from  job losses and Medicaid cuts. They were based on needs we are already experiencing.  

The county executive’s proposed FY27 operating budget—released this month—includes only 16% of the requested funding.  Most of our request for sustainable compensation, payment for volume growth, and right-sizing our staffing to operate these programs was not met.   

Our health care safety net is fraying. At a minimum, it is critical that the Council maintains the funds that are included in the CE’s proposed budget: $1.5 million in provider reimbursement, $19,440 in endodontic staffing, and $16,876 in specialty dental care for Care for Kids participants. 

Funding our safety net—even amid deep uncertainty—is partly about putting our collective money where our values are. But it is also aout recognizing an area of clear budget wins: our ability to transform core county investments into an incredible return. Our favorite example? A roughly $400,000 investment in PCC staffing helps patients secure more than $8 million in free prescription medications through pharmaceutical assistance programs. Those are better health outcomes from patients having the tools they need to manage conditions and an exponential increase in the volume of medications we can provide with County dollars. At $200 in value for every $1 invested, it is the ultimate win. 

Similarly, the estimated value of a single primary care visit at partner health centers is $250, assuming Medicaid payment rates. The FY25 reimbursement rate is $113/visit. That flat visit fee is the only direct Montgomery Cares funding partner health centers receive for the comprehensive care they provide. The entire scope of colorectal cancer screenings, educating patients on diabetes management, administering vaccinations, navigating patients to specialty care, and so much more is reimbursed at $113/visit. It is not enough to sustain this work.  

Without more support, our partners will be forced to scale back.  One partner already lost nurse practitioner capacity to the extra $10/hour another organization could offer. That NP did not go to concierge medicine or even private practice. That NP went to another safety net organization in Northern Virginia.  

We are in danger of losing the safety net, and it would be felt community-wide. It would mean more uninsured patients relying on emergency rooms for care that is ultimately uncompensated, driving longer emergency room wait times and higher insurance premiums for us all. These are not just long-term problems but areas of existing strain across our entire community.  

Investing in the safety net means neighbors getting the care they need to stay healthier, work and pay taxes, and contribute to our shared community. It is a high-value investment for us all. 

If you agree, consider testifying in support of these budget requests to the Montgomery County Council. In a tough budget year that also includes an election, our voices matter more than ever. Public budget hearings are April 7th-9th with options for submitting written testimony as well. Click here to sign up for live testimony (the deadline is April 3rd at noon) or here to submit written or video testimony.

Questions? Contact Stephanie Narayanan, Director of Development and External Relations at [email protected] 

Some additional advocacy resources:

• Council Vice President Marilyn Balcombe has published an Advocacy Guide.
• Councilmember Evan Glass has published a survey requesting feedback on budget priorities from county residents.

The Primary Care Coalition’s (PCC) commitment to early cancer detection continues to drive meaningful progress across our network, even amid significant administrative and operational underfunding. Despite these challenges, our cancer prevention and screening program remains a lifeline for uninsured and underserved community members. Its purpose remains clear: identify cancer early and intervene quickly.
 
The detection and treatment of cancer for patients without health insurance is extremely complex because it relies on a patchwork of programs for service delivery. “These gaps create inequity across the system by age, sex, and site,” says Dr. Veronica X. Vela, Senior Director for Healthcare Access. “Currently, there are no dedicated resources to oversee and improve the network of safety-net programs that constitute the continuum of care. Lack of dedicated oversight and facilitated coordination compromises the safety net's ability to diagnose and treat patients early, exacerbating healthcare costs.”

PCC’s cancer prevention and detection program leverages multiple funding sources and partnerships to provide screening for breast, cervical, and colorectal  cancer. Among them is the Breast and Cervical Cancer Program (BCCP), which provides direct screening for breast and cervical cancers through a combination of state and federal funding. Funds for BCCP come from the Centers for Disease Control and Prevention Award – 93.898 Cancer Prevention and Control for State, Territorial, and Tribal Organizations and MDH Center for Cancer Prevention and Control. Although it is currently the most resourced program within PCC, BCCP operates at only two partner health centers, with participation fluctuating due to its administrative requirements.
 
Across cancer screening types and funders, there are persistent challenges. Many of them are structural: patients need more navigation support across a fragmented service landscape and social access barriers, Montgomery Cares mammogram eligibility has not kept pace with US Preventive Services Task Force screening guidelines, and funding is insufficient for the administrative and operational responsibilities across screening programs.
 
Even in the face of these challenges, PCC continues to make meaningful strides. The program team established a partnership with Exact Sciences to provide free Cologuard colon cancer screening tests and supported rollout across five partner health centers . This reduced barriers for Montgomery Cares patients and brought more than $120,000 in donated testing capacity to uninsured residents in just the first half of this year. A state audit commended strong PCC program performance in breast and cervical cancer screening services.
 
Better early detection is crucial amid a rising overall cancer burden among Montgomery Cares patients. Since 2021, the number of cancer care patients has more than doubled, from 114 to 264, and the number of hematology and oncology appointments required to support these patients has more than tripled. In FY25, PCC coordinated 450 cancer care appointments, up from 139 in 2021. Where possible, PCC leverages grants from the Maryland Cancer Fund, a program of the MDH Center for Cancer Prevention and Control, to support treatment costs. An additional 31 colonoscopies were coordinated for patients who could not be served by the State-funded Cancer Crusade program, which was temporarily closed to new patients. While absolute numbers remain modest, the impact of access to cancer care for each patient is substantial.
 
“A dedicated navigator would ensure timely treatment for all patients and  support patients moving from diagnosis to treatment,” explains Vela. “Currently this work is absorbed by the Project Access Clinical Lead, which takes time away from reviewing specialty care referrals for the broader Montgomery Cares population, slowing down access to specialty care for other patients.” 
 
Given these obstacles, PCC has identified priorities to strengthen the continuum of cancer care for uninsured resident, including securing funding for program management, expanding breast cancer screening eligibility to women ages 40–44, and establishing patient navigation as a core program service.
 
PCC’s cancer prevention and screening program remains a vital resource for uninsured and underserved communities. “Despite funding gaps, fragmented services, and systemic barriers, PCC remains committed to early detection, equitable access, and continuous improvement,” says President and CEO Annice Cody, “ensuring every patient has the opportunity for timely, lifesaving cancer care.”

​The Pan Asian Volunteer Health Center at the Chinese Community and Culture Center (CCACC) provides a crucial healthcare access point for Chinese-speaking patients. But CCACC is committed to providing care for local patients with unmet needs, regardless of culture or origin. “Over the years, the clinic has provided free, high-quality care to thousands of patients — not only Chinese Americans, but also people from many other backgrounds,” says Kate Lu, the clinic director and mental health provider.
 
CCACC’s outreach efforts have focused not just on the Chinese American community but on the health center’s surrounding geography, with recent outreach at local senior centers and health fairs. Those efforts are showing, not just in patient numbers but in other demographics as well. The top two languages spoken and race/ethnicity categories remained the same from FY24 to FY25—Chinese (Mandarin) and Spanish, Asian and Hispanic/Latino, respectively. But the proportion of Spanish speakers grew from 41% in FY24 to 52% in FY25, while the percentage of Hispanic/Latino patients grew from 43% in FY24 to 53% in FY25.
 
Meanwhile, CCACC has provided more visits overall: 1,786 total visits in quarter two of FY26 (July 2025-June 2026), up 20% from the 1,484 visits provided in Q2 of FY25. The Montgomery Cares (MCares) patient visits have increased as well, at 669 in Q2 of FY26 versus 524 in Q2 FY25, an increase of nearly 28%. To provide those visits, the health center relies on both staff and volunteer providers: the equivalent of two full-time staff members in Q2 and volunteer time representing about 67% of another full-time position.
 
The health center’s services are not limited to scheduled visits; they also provide programming for health promotion. The center’s annual health fair in October offered screenings for common health concerns like blood pressure and bone density, as well as medical consultations. Each month, the center offers a different area of focus for patient education and free health screenings, and online seminars in Chinese help build the tools for wellness. Recent Zoom seminars ranged from the process of obtaining health insurance to understanding common concerns like gut health and pain management.
 
With federal funding support, CCACC officially relocated to a new and improved health center location (9298 Gaither Road, near its previous site in Gaithersburg) in December 2025. The new site has space for planned expansion into dental and pharmacy services.  CCACC also secured cost sharing funding from Maryland and Montgomery County to equip the new space and expand the scope of whole-patient care.

PCC supports the Asian American and Pacific Islander (AAPI) community through its partnership with the Asian American Health Initiative (AAHI), part of the Montgomery County Department of Health and Human Services. The goal is to develop and offer a suite of capacity-building programs to advance health equity for AAPI communities in Montgomery County.

The AAPI population in Montgomery County includes long-time residents and newly arrived immigrants from diverse ethnic groups such as Chinese, Korean, Vietnamese, Indian, Filipino, and Nepali communities. Yet these communities continue to face significant gaps in care. In 2021, only 25% of Asian adults with a mental health condition received treatment, compared with 52% of White adults. AAPI health issues have also been historically underfunded, representing just 0.2% of federal health-related grants between 1986 and 2000. These disparities highlight the need for culturally responsive investment. According to Rachel Lee, Director of Community Resilience, “We provide both strategic and hands-on support to help the organizations who support the AAPI communities grow.”

One way PCC advances this work is through its annual capacity-building workshops held from December through February. This three-part virtual series helps AAPI-serving nonprofits strengthen their grant-seeking skills by offering practical guidance on prospect research, tools like Grants.gov and eMMA, and today’s funding landscape.  It also featured sessions on writing compelling grant narratives, developing accurate budgets, and identifying local, state, and federal funding opportunities. Participants took part in hands-on exercises on FTE calculations, indirect costs, fringe benefits, and real-world grant databases. “Given the changes over the last 12 months, it’s more important than ever for organizations to be proactive in managing themselves, as well as their grant funding efforts,” says Rachel.  And why, she added, that they saw a record number of participants attend this workshop. For those who couldn’t attend, the workshop can be viewed at https://aahiinfo.org/aace/ and https://aahiinfo.org/aace-workshop-archive/ .
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The Capacity-Building Workshops are just one of the initiatives AAHI has planned for 2026. Rachel explains, “We’re organizing a two-day grant writing bootcamp to equip participants with the essential skills and tools to craft a competitive grant proposal. By the end of the program, attendees will have a complete and ready-to-submit grant application.” Additionally, they’ll be hosting a Health Equity Roundtable to delve into the impact of Social Determinants of Health on the well-being of Asian American and Pacific Islander communities. So, keep an eye out for these exciting events.