About Nexus Montgomery

The Mission

The six hospitals operating in Montgomery County, Maryland have joined forces with a network of community-based organizations to form the Nexus Montgomery Regional Partnership. Nexus Montgomery is a hospital-led collaborative that aims to reduce avoidable or unnecessary hospital use (including readmissions), by connecting people to timely and appropriate community-based care and support services.

A Historic Commitment

In Montgomery County, six local hospitals have recognized the value of forming a partnership to address common challenges. The Nexus Montgomery hospitals serve the same community and share patients. Among Medicare high utilizers (people with three or more hospital admissions in a year), 57 percent were readmitted to a different hospital. Among Medicare patients with two hospital admissions within a year, 35 percent used more than one hospital. While Nexus Montgomery participating hospitals are separate and distinct organizations in many ways, we are also partners, working together to improve the health of our community.

What does Nexus Montgomery do?

Nexus Montgomery invests in programs and initiatives that will improve the health of people who are at high risk of an adverse health event, or who have complex needs. By keeping people healthy and connecting them to appropriate community-based care, Nexus Montgomery initiatives reduce avoidable hospital use, reduce the total cost of hospital care, and generate a return on the initial investment. Nexus Montgomery partners are currently collaborating on four interconnected programs:

  • Hospital Care Transition¬†programs support people as they transition from hospital to home, with the goal of reducing the rates of readmission within 30 days of being discharged.
  • Wellness and Independence for Seniors at Home (WISH) provides free, confidential health surveys for seniors with Medicare who live independently in the community. WISH identifies people in jeopardy of declining health, and connects them with the services and support they need to remain independent and out of the hospital for as long as possible.
  • Capacity Building for the Severely Mentally Ill initiatives include the addition of an eight-bed crisis house and an Assertive Community Treatment (ACT) team, which uses an evidence-based model to treat patients with severe mental illness and keep them healthy, stable, and connected to community-based care and support.
  • Project Access is a specialty care referral network serving low-income, uninsured individuals. Nexus Montgomery provides funds for uninsured people at risk of hospitalization, or who have recently been hospitalized, to receive needed specialty care.