Programs

Skilled Nursing Facilities (SNF) Alliance

Improving education, communication, and collaboration among hospitals and post-acute care providers to improve care transitions and patient outcomes.

The SNF Alliance is a learning collaborative convened and facilitated by Nexus Montgomery. The Alliance is made up of 26 skilled nursing facilities in Montgomery County and two in Prince Georges County. In collaboration with the Nexus Montgomery Hospitals, the alliance is working to reduce readmissions and improve patient outcomes through strengthening the implementation of best practices, pooling knowledge and experience to optimize patient care, and improve the collaboration with the Nexus Montgomery hospitals.

One example of this; Skilled Nursing Facilities identified behavioral health care as a gap in current resources. Patients with behavioral health concerns have a higher risk for a readmission due to problem behaviors. By providing knowledge and skills to the front line staff to better manage these behaviors and intervene to de-escalate, enables the SNFs to maintain these patients in house, improving their outcomes.

Nexus Montgomery provides data management and analysis for organizations participating in the SNF Alliance through PointRight. This analysis allows Nexus Montgomery to work with SNFs to track progress on established goals to reduce hospital readmissions, provide training on how to integrate the use of data into their workflows, and host meetings to share quality improvement best practices.

Engagement Goals for SNF

Nexus Montgomery established seven engagement goals as the basis of the initial year of the Alliance. Facilities that completed all seven goals will be added to a Nexus Montgomery preferred provider referral list for post discharge care.

  • Upload minimum data sets
  • Regularly attend monthly SNF Alliance meetings
  • Participate in web trainings
  • Participate in PointRight office hours
  • Integrate PointRight data into existing workflow
  • Meet with Nexus Montgomery at the Facility
  • Implement a Quality Improvement Plan

Regional Partners

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Adventist HealthCare
Shady Grove Medical Center


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Holy Cross Germantown Hospital


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Adventist HealthCare
Washington Adventist Hospital


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MedStar Montgomery Medical Centar


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Holy Cross Hospital


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Suburban Hospital


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