If you’re reading this, you are likely part of an organization trying to make maximum impact in a world of limits. As you consider the many possible routes to good change, I have one piece of advice: Chart a clear course.  

Not long ago, I had the opportunity to shadow a community health advocate at one of our Social Health Alliance partner hospitals. I went in expecting to observe a workflow — a screening tool, a referral platform, a process. What I left with was something harder to categorize.

It’s easy to focus on process improvement from an efficiency lens: how can we streamline our efforts to do more work, better. We use that lens too, but we do not stop there. Improving processes is an equity strategy, not just an operational one. 

For people with health insurance, colorectal cancer screening is an unpleasant “to do” item every 5 – 10 years. For those without insurance, screening and, if needed, access to diagnostic and treatment services may be aspirational, not something easily checked off a list.

What do you get from a storytelling show besides a great evening and a YouTube video? If it’s PCC’s 2025 storytelling show, the answer just may be a timely primer for navigating into the new year. Consider these thematic highlights as the reminders we all need right now.

The Montgomery Cares (MCares) clinical quality reportis an annual PCC publication. It’s also a living document that reflects an evolving safety net care network and a changing environment.

In addition to program wins, we also flagged emerging threats to the health of our patients and the operation of this safety net system. Here are three areas where we are seeing the impact of challenges, which could worsen if not addressed.

I’m not suggesting we celebrate the very real crises that are likely coming, but I am suggesting we focus on where there are opportunities.

When our founders looked for ways to serve uninsured neighbors, they didn’t start with what was missing. They started with what we already had—and asked how we could use it to help more people.

Our vision is a vibrant community that supports all people in living healthy lives. It would be easy to focus on the health part of that vision, particularly in light of the day-to-day work we do, but I wonder if that isn’t somehow missing the point. Our lens is health and health care, certainly, but our vision is one of community.

Consider the role your spine plays in your body. It is the core structure for both stability and motion, as well as the central pathway for messages to and from different sectors. A healthy backbone, in other words, is an instrument of both communication and alignment. 

As a community, we take safety net health care for granted because it has been so long since we've seen widespread limits on access to care.

The same reasons our local hospitals collaborate on community investments through the Nexus Montgomery Regional Partnership apply in managing social service referrals as well: our hospitals have overlapping patient populations. Multiple referrals from multiple hospital touchpoints are not likely to improve patient resources.

If there’s one thing organizations try to avoid during times of upheaval, it’s leadership change. Why add another variable to an already confounded mix? But change happens, whether we plan it or not, and PCC’s outgoing President and CEO, Leslie Graham, knows a thing or two about how disorienting—but ultimately affirming—it can be.

There is something truly crystallizing about having to choose an angle and tell your story in an eight-minute time frame. It’s a gentler version of the elevator pitch because you have time for supportive—even sentimental—details, but you’re still forced to cut most of the fluff. 

To find out how well the Montgomery Cares (MCares) program meets the needs of current and potential patients, 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 Network Adequacy Study and report on the results*. What did we learn about the process and our system as we look toward improvement?

Delaying onset of the major consequences of chronic disease saves money—keeping people healthy allows them to be economically productive, and it reduces expensive medical costs such as hospitalization and dialysis. However, because chronic disease consequences build over time, the savings are in the future. It is a perfect area for public healthcare financing.

With the promise of rapid communications capability and new technological tools, it should be easier than ever to make sure the client we’re referring to another organization for services actually receives them. Yet we’d wager anyone who attempts to operate in closed-loop referrals has their own list of limitations. Our recent Nexus Connect project provided screening and referral for health-related social needs for under-resourced residents in two Montgomery County ZIP codes through funding from the Maryland Community Health Resources Commission (CHRC).* It also inspired thought on the caveats we recommend for like-minded efforts. 

Well-designed grant programs are not supposed to stress test nonprofit organizations. They are supposed to be partnerships for impact. If the grantee organization fails, we all do, because the end-recipient is not served.