The Maryland Consortium on Coordinated Community Supports, in partnership with the National Center for School Mental Health at the University of Maryland School of Medicine, has released a Resource Guide for Culturally Responsive Care designed to strengthen healing-centered and trauma-informed practices in school-based behavioral health. The document creates an index  of tools and research to support educators and service providers in creating inclusive, affirming, and supportive school environments.

Designed for K–12 educators and child and family service providers, the resource guide is divided into the following sections:

• Fostering cultural humility & self-reflection 
  
• Promoting family engagement 
  
• Affirming youth & family cultures and identities
  
• Supporting newcomer (immigrant and refugee) youth & families
  
• Intergenerational & interlinguistic parent-child dynamics & relationships
  
• Healing from historical & racial trauma 

The resource guide offers practical support for professionals committed to meeting the diverse needs of students and families while centering equity, cultural responsiveness, and healing. Access the full resource guide with this link.

Montgomery Cares (MCares) supports uninsured Montgomery County residents by offering access to a network of medical providers for primary care, behavioral health services, specialty care, dental care, and medications – serving nearly 25,000 residents annually.

The Primary Care Coalition (PCC) recently concluded reporting for the first half of FY26, and we are sharing the impacts made within our community. Those include cancer screenings, improved medication access, and efforts made to strengthen our safety net through system coordination and collaborative planning with community stakeholders.

In this companion to our March updates, we continue to highlight key progress made so far in FY26.

Strengthening Colon Cancer Detection Through Improved Testing

Last fiscal year, the Cancer Prevention and Detection team expanded access to lifesaving screening by partnering with Exact Sciences to eliminate application barriers for Montgomery Cares patients and provide Cologuard colorectal cancer screening kits at no cost (versus a typically cost of $681 per kit). Cologuard has a 94% sensitivity rate compared to 74% sensitivity rate with FIT tests (our previous screening methodology), improving the accuracy of test results.

As shown in the graph below, there has been a consistent increase in the number of screenings done each month as Cologuard was incorporated into clinics as a screening option (Seven of twelve health centers are using of Cologuard.) Our FY26 rates have already outpaced FY25 rates, with more adults getting screened for colon cancer.

Community Pharmacy and Med Bank Leverage Resources for Medication Access

Community Pharmacy supports health centers by supplying essential medications, vaccines, screening tools, and supplies for distribution at partner health centers. PCC program staff worked with medical directors to update the formulary with new medications and supplies that are needed by patients. In addition, they distributed 4,800 flu vaccines to all centers.

Medbank helps low-income patients access medications for chronic conditions through collaboration with over 40 pharmaceutical patient assistance programs (PAPs). PCC program staff helped 1,102 uninsured patients access life‑sustaining medications in the second quarter of FY26, delivering $2.4 million in no‑cost prescriptions, easing financial strain, and supporting continuity of care for patients while strengthening partnerships that make this access possible.

Strengthening Our Safety Net through Collaboration

Our team has been working closely with community stakeholders to assess external forces affecting service delivery. In our Access to Care strategy sessions—co-convened with DHHS—participants evaluated the strengths, vulnerabilities and opportunities for our existing network. They also explored alignment on shared goals, identified gaps between vision and outcomes, and prioritized key solution areas.  

Topics of discussion included:

• Keeping people on Medicaid
• enrollment and benefits navigation into MCares
• comprehensive primary care
• entry points and transitions to primary care
• economies of scale and financial stability for the safety net

Addtionally, PCC hosted a Health Center Manager’s Meeting to share key program updates and gather feedback on several programs were provided feedback on tools we are setting in place.

In partnership with CARECEN, PCC provided two sessions for executive and senior leadership, as well as frontline team members, on guidance in responding to law enforcement officials when approached. The session offered a space for these professionals to become prepared, confident, and aligned on how to appropriately respond if law enforcement contacts them. As MCares program serves a predominantly immigrant population, this information is essential to partners' ability to support patients navigating the current immigration environment. 

For the remainder of FY26 and beyond, these combined efforts reflect meaningful progress across the system and position MCares to remain responsive to changing needs while continuing to provide quality care for uninsured residents.

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

Hospitals across the Nexus Montgomery Regional Partnership, a collaboration among the six hospitals in Montgomery County, continue to face the complex challenge of caring for hard‑to‑place patients—individuals who no longer require acute care but cannot be safely discharged due to medical, behavioral, social, or placement barriers. These additional days in the hospitals are defined as administrative days. This system‑wide issue affects nearly every patient population, including youth, seniors, individuals with developmental disabilities and those with complex medical needs.
 
“Hard‑to‑place patients are a challenge across the entire continuum of care,” said Marnie Brennan, PCC Senior Program Coordinator, Population Health.  “In most cases, people are staying in hospital beds not because they need inpatient care, but because there’s no safe or appropriate place for them to go.” Patients may be waiting for skilled nursing facility (SNF) placement, lack a legal guardian, or have no stable housing options. PCC and the Nexus Montgomery hospital partners now track these patients and identify barriers earlier—supporting care teams in moving patients forward on their journey to wellness.

Encouraging Trends

There is positive momentum. Total administrative day encounters have declined through CY25, reflecting increased focus and coordination across the system. “We’re seeing the impact of paying closer attention to this issue,” Brennan said. “Reducing administrative days takes sustained effort, and the downward trend shows that our work is making a difference.”
 
While discharge to SNFs remains the largest outcome category for hard‑to‑place patients, an important shift occurred in the second half of FY25. For patients with fewer than five administrative days, discharges to home exceeded discharges to skilled nursing facilities. “That tells us we’re finding better, more appropriate discharge options for some patients earlier in their stay,” Brennan noted

What’s Driving Delays

The top ten diagnosis categories account for 64% of all administrative days among patients discharged to SNFs, with average days per encounter ranging widely—from 2.7 to 74.3 days. These diagnoses include cerebrovascular disease, medical and surgical complications, respiratory illnesses, hip and thigh injuries, diabetes, and hypertensive diseases—highlighting the individualized nature of discharge planning.

Pediatric ED Stays Remain a Concern
Another ongoing challenge is pediatric patients (under age 21) who remain in the emergency department for more than 24 hours. In FY25 alone, prolonged ED stays across the six Nexus Montgomery hospitals totaled the equivalent of nearly nine years of bed day. Eight of the top ten diagnoses associated with these stays involve behavioral health, substance use, or developmental disabilities, with average lengths of stay between 2.3 and 12.3 days.

“Holding children in the ED for extended periods is not appropriate due to the ED's restrictive and chaotic environment, and it places strain on patients, families, and staff,” Brennan said. “This data reinforces the need for stronger pediatric behavioral health pathways.” Nexus Montgomery’s efforts to address these challenges align with the state’s broader initiatives to reduce these barriers, guided by the Pediatric Overstay Workgroup.

Looking Ahead

While hard‑to‑place patients remain a complex challenge, continued collaboration, data‑driven tools, and a system‑wide focus are producing measurable progress. “We still have work ahead,” Brennan said, “but the trends show we’re moving in the right direction—toward better outcomes for patients and a stronger, more efficient healthcare system.”

The Lutheran Church of St. Andrew is an example of compassionate care in action through its robust medical supplies and equipment ministry. Open to all and offered with no means assessment required, the program supports a wide range of needs, including incontinence products, canes, crutches, walkers, shower chairs, wheelchairs, wound care items, diabetic supplies, blood pressure monitors, pulse oximeters, and thermometers.

“This ministry is open to anyone who needs help,” says Marilee Tollefson, Faith Community Nurse. “We serve individuals and families throughout Washington, DC, Maryland, and Virginia, and our goal is to remove barriers so people can receive the care and equipment they need with dignity.”

Those seeking assistance are invited to call or text Marilee at 301‑254‑9115 to schedule a pickup appointment.

St. Andrew has grown and flourished through decades of dynamic ministry—first in Wheaton and later in Cloverly, following its relocation in 2008. The congregation proudly celebrated its 75th anniversary in 2024, honoring a legacy of service, faith, and boundless blessings for the community. The church is located at 15300 New Hampshire Ave., Silver Spring, MD 20905.

In Fiscal Year 2026, the Primary Care Coalition (PCC) has been working with the Montgomery County Department of Health and Human Services (DHHS) to expand access to reproductive health services for youth enrolled in Care for Kids. PCC is pleased to report those services are now covered by CFK at two partner health centers—a major milestone toward support for uninsured youth to make informed choices about their reproductive lives.

Unintended pregnancy impacts youth achievement and mental wellbeing

Having a baby as an adolescent can be disruptive to young women’s education. One study found that at age 22, almost 40% fewer teen mothers had completed a high school degree than their non-parenting peers (Perper, Peterson, Manlove, 2010). In Montgomery County, about a third of young mothers stop attending high school (Metcalf, 2016). Adolescent mothers are also likely to experience pre-eclampsia, which is known to reduce oxygen and nutrients to the growing fetus and cause preterm births, low-weight births, and require neonatal intensive care (Parra-Pingel et al, 2017; Brosens et al., 2018; Hoffman and Maynard, 2008). Once the baby is born, young mothers are more likely to experience postpartum depression than mothers who delayed childbirth (McCracken and Loveless, 2014).

Fatherhood is also stressful on young men. Despite limited research in this area, several qualitative studies illustrate that young fathers experience depression, social isolation and anguish over how they are going to complete school or find employment (Park and Neville, 1987). Other quantitative studies show that young fathers are 20% less likely to obtain their high school diploma (Fletcher and Wolfe, 2012).

Data suggest CFK teens are at higher risk

The CFK program, administered by PCC with core funding from DHHS, provided access to health care for more than 10,000 uninsured children and adolescents in FY25, with more than 40% of participants aged 13-19. Adding reproductive health services is critical because being uninsured increases teen pregnancy odds by an estimated 74% (Miller, Graefe, Jong, 2013).  Ethnicity is a key factor as well.  Birth rates in Montgomery County among teens who are Latina are twice as high relative to their peers who are White or Black/African American (Metcalf, 2016), and more than 80% of CFK patients identify as Latino/a.

New offerings preview further service design

Pediatricians play a key role in preventing unplanned pregnancies and sexually transmitted infections (STIs), including HIV, and advocating for healthy relationships (Marcel et al., 2017). To balance meeting immediate needs and designing comprehensive services, PCC and DHHS agreed on a phased approach. Phase 1 would focus on quick availability of reproductive health services at partner sites with existing capacity—providing a reimbursement mechanism when CFK participants need these services. We have reached that milestone, with services reimbursable at two participating health center organizations: CCI Health & Wellness and Mary’s Center. Phase 2, now underway, will explore preferences, provider capacity, the policy landscape, and service best practices around which to design CFK service solutions. The end goal is to make respectful, patient-centered reproductive health services accessible across the CFK network.

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

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.