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.
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.
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.
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.
Through this collaboration, Nexus Montgomery supported development of new services to fill gaps in the existing system of care.