Nexus Montgomery is a partnership among the six hospitals in Montgomery County that connects people with resources in the community that will help them remain healthy and independent.
Patients often receive care from more than one hospital. Nexus Montgomery formed because hospitals can better serve the community by working together. Our programs improve the health of the community by supporting coordinated services that are tailored to the needs of individuals. Our focus is on addressing the medical and social factors that contribute to health and wellbeing.
Wellness and Independence for Seniors at Home (WISH) provides free, confidential health surveys and health coaching to seniors with Medicare who live independently in the community and are at high risk for hospital use.
WISH aims to reduce avoidable hospital use by connecting older adults to the services they need before their health declines. People who are at high risk for hospitalization receive ongoing health coaching from WISH. Health coaching helps older adults remain independent so that they may age-in-place.
Hospital Care Transitions
Hospital Care Transitions programs support people as they transition from hospital to home, with the goal of reducing rates of readmission within 30 days of being discharged.
Each Nexus Montgomery partner hospital provides care transition services to patients at high risk for readmission. Nexus Montgomery provided additional funds to scale up the existing hospital care transition programs that are shown to decrease emergency department use, reduce 30-day readmissions, and stabilize patients at home.
Project Access is a specialty care referral network composed of a dedicated group of physician specialists, diagnostic facilities, and local hospitals that participate in a coordinated effort to provide specialty care to people who are uninsured and have limited resources.
Project Access helps people gain timely access to needed specialty care, potentially preventing more severe medical problems, avoiding acute hospitalizations, and reducing health care costs.
Capacity Building for the Severely Mentally Ill
In Montgomery County, hospitals have frequently housed patients who are experiencing a mental health crisis because of a lack of appropriate referral options. Hospital emergency departments are not the best therapeutic environment for individuals experiencing a mental health crisis, and housing individuals in hospital emergency departments is extremely costly.
Nexus Montgomery has invested in three initiatives to increase capacity to serve severely mentally ill individuals in the community: Opening a new 8-bed crisis house to treat people experiencing a mental health crisis; establishing an additional Assertive Community Treatment team to support mentally ill patients not suited to traditional treatment settings; and, providing staffing to sustain inter-agency collaboration to reduce hospital use by severely mentally ill patients.
The Skilled Nursing Facility (SNF) Alliance is a learning collaborative convened and facilitated by Nexus Montgomery. The Alliance brings together 37 SNFs and the six Nexus partner hospitals to reduce readmissions and improve patient outcomes through implementing best practices to optimize patient care. Through the Alliance, participating SNFs are provided with data management, analysis, and quality improvement support to track/improve upon 30-day readmissions and other quality metrics.
Nexus Montgomery partners collaborate on five interconnected programs:
Wellness and Independence for Seniors at Home (WISH) will stabilize the health of older adults
Hospital Care Transitions programs will improve transitions from hospital to home
Project Access will connect people without health insurance to specialty care followups
Capacity Building for the Severely Mentally Ill will expand community based resources
The Skilled Nursing Facility (SNF) Alliance will promote collaboration among hospitals & post-acute care providers
Shady Grove Medical Center
Holy Cross Germantown Hospital
White Oak Medical Center
MedStar Montgomery Medical Center
Holy Cross Hospital