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.
Voice Your Choice supports patient-led care and decision-making. Through on-demand online trainings, educational resources and increased public awareness, the program will expand the number of individuals who have identified their health care proxy and completed an advance care plan. This includes people who have uploaded those plans to a secure platform for easy provider access.
Nexus Montgomery seeks to improve quality of care and ensure that providers can respect their patient’s wishes by supporting this community-wide program, which will increase awareness of advance care planning and remove barriers to completing and accessing advance directives.
To learn more about Voice Your Choice and complete your advance care plan, please visit voiceyourchoice.org
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.
DPP programming offers individuals a 12-month group education program focused on lifestyle change to reduce the risk of diabetes. DSMT programming offers diabetes management education by certified diabetes Educators, offered to diabetic patients in order to improve control & management of diabetes.
The Nexus Montgomery Diabetes Program will focus on twelve ZIP Codes in Montgomery County that represent nearly 500,000 residents and a significant portion of the Nexus Montgomery hospitals’ diabetes-related admissions. Given the racial and ethnic demographics of these areas, targeting these ZIP Codes creates provides an opportunity to close long-standing disparities.
The Nexus Montgomery Diabetes Program will be implemented through collaboration with a wide range of community partners serving as DPP or DSMT providers and referral or outreach partners. DPP or DSMT provider partners will receive intensive support for start-up of new programs or expansion, including stipends to offset initial, un-reimbursable costs, contingent on ongoing process improvement participation. The Diabetes Program has three other key implementation partners: a public outreach partner attuned to the input of our diverse community, a centralized referral and case management partner, and the Brancati Center for its technical assistance and expertise in DPP programming.