The six hospitals operating in Montgomery County have joined forces with a network of community based organizations to design and implement programs that will improve the health of our community overall, increase people's satisfaction with their health and health care, and encourage efficient health care spending.
Health care delivery in America has been described as a "disease care system", because payment for services is based on units of care, rather than results. Maryland is doing something different. The state commission that regulates hospital rates has set ambitious quality of care, population health, and spending goals in order to shift financial incentives to reward results instead of volume. To achieve these goals, hospitals must work with community organizations to coordinate better, more holistic care, and to create healthier communities.
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.
Nexus Montgomery partners collaborate on four 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
Specialty care for the uninsured will connect people without health insurance to specialty care followups
Capacity building to serve the severely mentally ill will expand community based resources
Shady Grove Medical Center
Holy Cross Germantown Hospital
Washington Adventist Hospital
MedStar Montgomery Medical Centar
Holy Cross Hospital