Montgomery Cares Quality Report Highlights Strength, Resilience, and Opportunity
Overall, the Montgomery Cares Clinical Quality Report for FY2025 shows that the Montgomery Cares network continues to demonstrate the power of coordinated, community-centered care for uninsured residents in Montgomery County.
As in Fiscal Year 2024, the report offered an expanded set of clinical quality measures—thirteen, versus eight in previous years—for a broader picture of both the network’s successes and the resources needed to continue improving outcomes for patients. The expanded set of measures reflects an important understanding: quality improvement is not only about clinical performance, but also about access, affordability, coverage policies, and the availability of essential resources. For patients participating in Montgomery Cares, many of whom face complex health needs and barriers to care, these measures help illuminate where the network is making progress and where continued investment is needed.
A population with significant health needs
Compared with Maryland residents overall, Montgomery Cares patients continue to experience a higher burden of several chronic and preventive health conditions. Diabetes affects approximately 21% of Montgomery Cares members, compared with 10.9% of Maryland residents overall. Hypertension is also more common in the Montgomery Cares population, affecting 39% of patients compared with 33.1% statewide. Cervical cancer rates are much higher as well, though the data only includes patient records on the PCC-managed electronic health record (approximately 40% of the patient population), underscoring the importance of sustained access to screening, follow-up care, and prevention services.
Strong performance across key measures
Despite these challenges, FY 2025 findings show that Montgomery Cares continues to perform strongly across many clinical quality measures when compared with the HEDIS national Medicaid average. This performance reflects the dedication of health centers across the network and their ability to deliver high-quality care to a medically complex population with limited resources.
Among the strongest results, HbA1c testing remained high at 90.4%, demonstrating continued attention to recommended diabetes monitoring. Hypertension control reached 68.7%, exceeding the national average, while diabetes blood pressure control remained a notable strength at 81.1%. Preventive care measures, including breast and cervical cancer screenings, remained near or above national benchmarks, reflecting sustained engagement in recommended screening practices throughout the network.
Challenges point to opportunities for partnership and investment
The report also identifies areas where additional resources could make a meaningful difference. Retinal eye exams for patients with diabetes remained a challenge in FY 2025, driven by gaps in screening resources and limited access to retinal specialists and equipment. PCC and the network are working in FY 2026 and FY 2027 to expand retinal screening access through partnerships with specialty care providers.
Another concern was controlled diabetes, which fell below the national HEDIS Medicaid average for the first time since 2016. Patient stress, behavioral health needs, and reluctance to leave home due to fears related to deportation may be contributing factors for some community members. In response, the network’s Community Pharmacy formulary added home HbA1c testing kits, helping make diabetes monitoring more accessible for patients who may be limiting travel outside the home.
Looking ahead
Continued investment in chronic disease management, preventive care, behavioral health services, and care coordination will be essential to sustain and expand progress across the Montgomery Cares network. Approximately 31% of patients with diabetes and 31% of patients with hypertension continue to have uncontrolled disease, increasing the risk of serious complications and avoidable healthcare utilization.
Expanding access to affordable blood pressure and HbA1c monitoring—in clinics and at home—will help patients better understand their conditions and take action. Care management also remains critical for patients with uncontrolled high blood pressure and diabetes, particularly when they need support accessing medications, specialty care, nutritious food, and other resources that contribute to health and stability.
Initiatives such as Food as Medicine programs, nutrition support, expanded medication access, specialty care partnerships, and statewide vaccine access programs can all play a role in strengthening outcomes in future years. Together, these strategies reflect PCC’s broader commitment to advancing health equity, supporting community-based providers, and ensuring that uninsured residents have access to the care and resources they need to thrive.