Our current programs maximize the reach and efficacy of our health care system, connecting underserved populations to vital care.

While the initial grant that established Nexus Montgomery has concluded, the partnerships have been so valuable that the hospitals continue to fund collaboration and the sharing of ideas.

Active Programs 

Skilled Nursing Facilities Alliance

Program Synopsis: Promoting education, communication, and collaboration among hospitals, skilled nursing facilities, and home health providers to improve care transitions, patient outcomes, and reduce hospital readmission.

Program Objective: To improve the quality of care for patients discharged from the hospital to skilled nursing facilities.
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Metrics for Success:
  1. Decreasing 30-day Return to Hospital Rate for Patients Discharged to SNFs
  2. Decreasing the time it takes for patients to return home after a SNF stay
  3. Decreasing Total Health Care Cost​
Program Details
The Nexus Montgomery Skilled Nursing Facility Alliance (the SNF Alliance) is focused on patients as they transition out of an inpatient setting and into their period of recovery at a skilled nursing facility and ultimately home. Ensuring these transitions are well managed and the patient is connected with the right on-going care in a timely manner is essential for the best outcomes for patients and prevents costly hospital readmissions.

Facilitated by Nexus Montgomery, the SNF Alliance is made up of 36 facilities in Montgomery and Prince Georges County. The participating SNFs and Nexus Montgomery hospitals collaborate on the understanding that reduced readmissions and improved patient outcomes require improvements on both sides of the transition. The SNF Alliance provides a venue for sharing knowledge and experience, collaborative problem solving, piloting improvements to optimize patient care, and implementing best practices.

Nexus Montgomery provides data management and analysis for facilities participating in the SNF Alliance. Through this data driven process, Nexus Montgomery also works individually with SNFs to engage with their data to understand their individual facility drivers for readmissions and quality outcomes and to test and implement interventions to improve.
Hard to Place Patients
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​Program Synopsis: Hard to Place Patients programming addresses challenges for patients who are medically ready for discharge but remain in the hospital due to access barriers in continuity of care involving limited capacity of services, insurance issues, or delays with a governmental service.  No patient should remain in the hospital after being medically ready for discharge.
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Program Objective: Reduction in total administrative days for patients with 5+ administrative days whose discharge plan depends on a governmental program.

Metrics for Success:
  1. Total patients with 5+ administrative days
  2. Total administrative days for those patients
  3. Progress to goal with community partners
Behavioral Health Programming 

Program Synopsis: The Behavioral Health program convenes stakeholders from all sectors that affect behavioral health care and crisis response in Montgomery County to reduce high utilization and strengthen the county's behavioral health crisis response.  Nexus staff lead workgroups comprised of representatives from Nexus hospitals, community-based provider organizations, and county agencies to decrease individual behavioral health patient hospital utilization, reduce violence against the hospital workforce, and shape policies and procedures to support the county's future 24/7/365 crisis stabilization facility. The program also includes facilitation and administrative support for the county's Behavioral Health Crisis Leadership Collaborative, which is comprised of hospital and county agency senior leadership, as well as community representatives. The Collaborative provides high-level oversight of all behavioral health crisis activities, facilitates cross-sectoral communication and collaboration, and monitors and evaluates progress on systemwide objectives.
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Program Objective: To reduce high hospital utilization among behavioral health patients; to expand and strengthen Montgomery County's behavioral health crisis response system. 
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Metrics for Success:
  1. Total ED encounters for high utilizer behavioral health patients
  2. Average ED encounters for behavioral health high utilizer patients 
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Nexus Connect

​Program Synopsis: Create connected pathways through community resources to improve health outcomes. Specifically addressing access to care, food insecurity, and early childhood education services in a hyper-targeted census tract area of Gaithersburg, Maryland.

Program Objective: 
  1. To improve access and appropriate utilization of preventive health services for the target population.
  2. To increase the utilization of financial assistance and development opportunities among underserved community members.
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Metrics for Success:
Community members receiving a closed loop referral to:

  1. Affordable health care, health insurance navigation and/or health education/disease management programming
  2. Financial Assistance (food access and tax preparation services)
  3. Early Childhood Education Resources
Workforce Capacity 

​Program Synopsis: The Workforce Capacity Program is a collaborative approach to workforce development, currently focused on training community members for technical positions widely needed across the healthcare landscape.

Program Objective: Expand the pipeline of culturally and linguistically diverse students who are new the workforce to ensure our health care workforce mirrors our diverse community and to support economic empowerment for under-employed residents.  
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Metrics for Success: Total enrolled, graduated, and placed in entry-level health care careers.
Completed Programs

Nexus Montgomery has operated complex programs since 2016. See the results!
About Nexus Montgomery

We're building a community where patient care is consistent no matter which hospital Montgomery County residents visit. 
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