Nexus Montgomery is a transformative initiative expected to improve the quality of life and stabilize health of at risk community members. Programs are designed to contain per capita hospital costs and potentially avoidable hospital use—especially emergency department use and readmissions. Through its focus on collaborative learning, shared resources, and process improvement, Nexus Montgomery will ensure continued good performance and jointly address systems changes that improve population health in the region now and into the future. Each Nexus Montgomery Program has associated performance indicators which are reviewed monthly by the Partnership Program Intervention Committee (P-PIC), composed of representatives from each participating hospital as well as a number of community partners. Hospital Care Transitions (HCT) 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. This expansion of existing HCT programs will provide needed care transition services to more than 19,000 individuals throughout our community in 2017. Wellness and Independence for Seniors at Home (WISH) provides free, confidential health surveys for seniors with Medicare who live independently in the community. As of February, 2017, WISH provided health coaching and care coordination services to more than 300 individuals and aims to serve at least 3,700 patients in 2017. WISH client satisfaction surveys show the program is exceeding expectations of both seniors and their families. 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. More than 120 people gained access to needed specialty care through this program as of March, 2017, with a goal of serving 265 patients in calendar year 2017. Serving those with Severe Mental Illness is essential as these individuals require additional support to avoid hospital use and live a productive life within the community. Nexus Montgomery funded the startup of an Assertive Community Treatment (ACT) team which has served nearly 50 residents and is continuing to serve more. A new 8-bed crisis house is open and operational, this resource is expected to provide appropriate, and community based care for 230 patients per year. 90% of whom would be hospitalized without access to this resource.

Regional Partners

Image 4_1 Adventist HealthCare Shady Grove Medical Center Visit website Image 4_2 Holy Cross Germantown Hospital Visit Website Image 4_3 Adventist HealthCare Washington Adventist Hospital Visit Website Image 4_4 MedStar Montgomery Medical Centar Visit Website Image 4_5 Holy Cross Hospital Visit Website Image 4_6 Suburban Hospital Visit Website