Program areas at PCC
Latino health initiative: por nuestra salud y bienestar (lhi-pnsb) began in fiscal year 2021 in response to the inequities many latinos faced in Montgomery County with covid-19, including having essential jobs, higher poverty rates, reliance on public transportation, tight living conditions, lack of health insurance, and a greater incidence of pre-existing health conditions like diabetes. On behalf of the Montgomery County latino health initiative, the Primary Care Coalition coordinates multiple local nonprofit partners providing covid-19 outreach, education, testing, and clinical follow-up, as well as case management, mental health services, and access to emergency assistance. Montgomery County now has one of the highest covid-19 vaccination rates among latinos in the country.
Nexus Montgomery aims to keep people healthy and out of the hospital by connecting them to timely and appropriate community-based Care and support services. Nexus Montgomery is a collaborative effort among the six hospitals serving Montgomery County Maryland. The Primary Care Coalition has served as the management entity for nexus Montgomery since its inception in 2015. Pcc provides organizational infrastructure, program staffing, data analytics, and operationalizes the programs with direction from the nexus Montgomery management board. In fy22, nexus Montgomery expanded its programming related to behavioral health, faciliting strategic discussions and tactical planning among Montgomery County departments of fire/rescue, police, health and human services, and local behavioral health providers, and the six local hospitals. Nexus Montgomery also ramped up a diabetes program that has a three pronged approach: 1) build the number and sustainability of community diabetes education providers, 2) build demand from community members and their referring physicians for these program, and 3) provide case management to diabetes class enrollees to support their continuation and completion of their program.
Montgomery cares provides health Care to adults who live in Montgomery County, Maryland and have incomes below 250% of the federal poverty level. In fiscal year 2022, 21,940 patients received services through Montgomery cares including Primary and preventive health visits, behavioral health services, referrals for specialty Care, and access to medications. Montgomery cares is a public-private partnership composed of 10 independent safety-net Primary Care clinics, six hospitals, the Montgomery County department of health and human services, and the Primary Care Coalition, as well as volunteer health practitioners and other community-based organizations. The Primary Care Coalition administers Montgomery cares and is responsible for coordinating the services of the participating health Care providers.
Care for kids provides affordable Primary, specialty, behavioral health, and dental Care for children of low-income families in Montgomery County who are not eligible for other state or federal health programs. In fiscal year 2022, more than 7,900 children received services ranging from well child visits to case management for children with complex medical needs. Care for kids is a public-private partnership composed of the Montgomery County department of health and human services, Montgomery County school based health centers, private health Care providers and safety-net clinics, kaiser permanente of the mid-atlantic states and the Primary Care Coalition.
Other programs and services the Primary Care Coalition works on many levels to increase access to health Care and improve the health and lives of our neighbors who are experiencing vulnerability. We connect people to services. We support health Care providers with technical assistance in areas including quality assurance, data analysis and health informatics, and process improvement. We build systems by engaging diverse stakeholders to discuss shared challenges and develop systems of Care that meet the needs of our community. Examples of additional pcc programs designed to improve systems of Care for vulnerable residents:- food is medicine is a program that creates a pathway between health Care services and food assistance programs. Facilitating reliable access to healthful food is improving health outcomes for people identified being food insecure and having diabetes or pre-diabetes.- connecting to health coverage. The Primary Care Coalition serves as the performance manager for the capital south region connector program, which assists prince georges County residents in enrolling in medicaid and private health insurance coverage through the Maryland health connectionxthe state-based insurance marketplace.- point of entry project (pep). Working with Montgomery County public schools international admissions, a pcc client navigator connects newly immigrant families with Care for kids and social services.