Hospital Care Transitions

Hospital Care Transitions 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. Care transitions are the processes people go through as they move from one care setting to another, for example moving from a hospital to the person’s home. When care transitions are not well managed, it can negatively impact the health of the patient and result in costly readmission. Therefore, coordinating these transitions is an important step in preventing readmissions and containing hospital costs. Each Nexus Montgomery partner hospital provides care transition services to patients at high risk for readmission, however, resource constraints have prevented hospitals from addressing the needs of all patients who could benefit from care transition support. Often, these patients are a “shared population,” accessing care at multiple hospitals and making the implementation of a transition plan more complicated than necessary. Nexus Montgomery has established a number of systems improvement projects, including a facilitated learning collaborative that brings hospital staff together to share data and best practices. By working together, the hospitals can create a uniform system that uses the same criteria to determine which patients receive care transition services, ensure that the same patients are not being over served by more than one care transition program, collaborate to solve common challenges, and share effective strategies. To learn more, please contact Susan Donovan, Director of Population Health,

Regional Partners

Image 4_1

Adventist HealthCare
Shady Grove Medical Center

Image 4_2

Holy Cross Germantown Hospital

Image 4_3

Adventist HealthCare
Washington Adventist Hospital

Image 4_4

MedStar Montgomery Medical Center

Image 4_5

Holy Cross Hospital

Image 4_6

Suburban Hospital