Five years of collaboration, testing initiatives for better health and care connections.
The Nexus Montgomery partnership has helped to decrease unnecessary utilization at Nexus Montgomery hospitals and contribute to nearly $38 million of gross savings in support of the Maryland Total Cost of Care model, leading to a positive return on an investment of $25 million.
Diabetes Prevention and Management
Program Synopsis: Through Diabetes Prevention and Management, Nexus Montgomery is helping to increase community capacity and participation in accredited Diabetes Prevention Programming (DPP) and Diabetes Self-Management Therapy (DSMT).
Program Objective: To decrease the incidence of Type 2 Diabetes and improve management for individuals with a previous diabetes diagnoses.
Metrics for Success:
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 focused 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 provided an opportunity to close long-standing disparities.
The Nexus Montgomery Diabetes Program was 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 received support for start-up of new programs and program expansion, including stipends to offset initial, un-reimbursable costs, contingent on ongoing process improvement participation. The Diabetes Program had 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.
Voice Your Choice
Program Synopsis: The Voice Your Choice program strives to ensure that a person’s values, wishes and preferences are respected during a health care crisis.
Program Objective: To increase the number of individuals who have created and electronically stored advanced care plans and identification of healthcare proxies.
Metrics for Success:
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
Hospital Care Transitions (HCT) Learning Collaborative
Program Synopsis: Supporting individuals transitioning from hospital to home through improved coordination and connection to community resources.
Program Objective: To improve transitions from hospital to home.
Hospital Care Transition programs support people as they transition from hospital to home, with the goal of reducing readmissions within 30 days of their discharge. Each Nexus Montgomery partner hospital provides care transition services to patients at high risk for readmission or poor outcomes. Due to the geography of the service area, there are a number of patients who discharge from one hospital, but readmit to another. This “shared population” represent a challenge for the individual hospitals, requiring coordination not only with post-acute providers, but coordination across the hospitals.
Starting in 2016, each hospital received support through Nexus Montgomery to expand and enhance these care transition services. Nexus Montgomery also established and facilitated a Hospital Care Transition Learning Collaborative among hospital program leadership to address the challenges of their “shared population”, along with the shared challenges in moving patients to their next level of care. The Learning Collaborative reviewed data, shared best practices, reviewed challenges in discharging patients, and brought in outside stakeholders as pertinent to shared challenges.
As of July 2020, each Nexus Montgomery hospital is independently supporting these expanded care transitions programs. In its next phase of implementation, the Hospital Care Transition Learning Collaborative will evolve into the HCT Learning Forum, bringing the successes and experience of the Learning Collaborative to the front-line care transitions staff.
Wellness and Independence for Seniors at Home (WISH)
Program Synopsis: Wellness and Independence for Seniors at Home (WISH) provided free, confidential health surveys for seniors with Medicare living independently in the community.
Program Objective: To stabilize the health of older adults to increase community tenure.
Most seniors want to stay active, independent, and in their own homes. WISH—Wellness and Independence for Seniors at Home—helped many seniors to make that wish come true.
WISH worked with community partners to identify seniors who may be struggling with their health needs. WISH Health Coaches met with clients to discuss their goals and concerns, and to assess their health and risk factors that could lead to an adverse health event. Together, they developed a personalized plan to meet individual health and wellness needs, and identify and connect to community-based support. Many WISH participants reported improved sense of wellbeing and autonomy. Many have avoided repeat hospitalizations.
Specialty Care for the Uninsured
Program Synopsis: Specialty Care for the Uninsured helped people gain timely access to needed specialty care, potentially preventing more severe medical problems, avoiding acute hospitalizations, and reducing health care costs.
Program Objective: To connect uninsured individuals to specialty care.
Project Access is a specialty care referral network that works with primary care clinics, specialty physicians, diagnostic facilities, and local hospitals to provide timely and affordable specialty care to low-income, uninsured patients in Montgomery County.
Nexus Montgomery supported existing services for Montgomery County patients who had had hospital contact within 60 days. It also expanded the program’s reach to low-income, uninsured patients in Prince George’s County, regardless of hospital contact.
Project Access continues to be administered by the Primary Care Coalition. To learn more, please contact SpecialtyCare@primarycarecoalition.org.
Capacity Building for the Severely Mentally Ill
Program Synopsis: Capacity Building for the Severely Mentally Ill aimed to improve coordination among those serving individuals with severe mental illness so that patients received appropriate behavioral health care when they need it.
Program Objective: To improve community based resources for people experiencing severe mental illness.
Through this collaboration, Nexus Montgomery supported development of new services to fill gaps in the existing system of care.
An integrated Behavioral Health Workgroup brought together behavioral health professionals from across our six member hospitals and representatives of county emergency medical services and community health practices. Together, we exchanged experiences, approaches, and best practices better understand and ultimately reduced high hospital utilization by patients with severe mental illness.
Assertive Community Treatment (ACT) Teams support people with severe mental illness by providing ongoing care and support for patients in the community and coordinating access to services such as housing and employment assistance. With support from Nexus Montgomery, Cornerstone Montgomery added two new ACT teams with capacity to serve 200 individuals with severe mental illness.
Crisis House Patients experiencing a mental health crisis are often sent to the hospital because there are few other safe options. Crisis Houses provide a safe place to stabilize patients, but access to Crisis House beds was limited. Our investment with partners Cornerstone Montgomery and Sheppard Pratt Health System, has doubled the number of beds available in our area. Montgomery County residents now have access to 40 additional Crisis House beds, where patients experiencing acute mental health events are evaluated, stabilized, and ultimately connected to other appropriate medical and social services.
Outpatient Mental Health Clinic (OMHC) Referral Program: Nexus Montgomery partnered with Vesta Inc. and Cornerstone Montgomery improve access to psychiatric follow-up care for patients discharged from the hospital ED. This was accomplished by expanding the capacity of OMHCs and improving workflows to reduce wait times for services.
Mental Health First Aid (MHFA) Training Nexus Montgomery management staff at the Primary Care Coalition (PCC), received a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) to provide MHFA training to senior care providers in Nexus Montgomery service areas. The training helps front line care providers identify signs of mental illness and provide their patients with access to therapy, medications, and other resources to maintain their mental health.