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.

Completed Programs

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:
  1. Increased referrals into the DPP and DSMT programs
  2. The number of accredited DPP and DSMT programs available in the community
  3. Retention and outcomes of individuals participating in programs​
{title_0:text default="title 0"}
{content_0:content}
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:
  1. Increasing Community Program Reach
  2. Increasing Website Visits and Webinar Engagement
  3. Increasing Advance Care Plans Uploaded and available to Providers​
{title_0:text default="title 0"}
{content_0:content}
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.

Key Results:
  1. 10 HCT Learning Sessions per Year
  2. 1,388 Hospital Readmissions Prevented
  3. $19.6 Million Hospital Cost Savings 
{title_0:text default="title 0"}
{content_0:content}
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.

Key Results:​
  1. 1,200 Individuals Linked to Community – Based Resources Through WISH Programming
  2. Engaged 35% of Eligible Medicare Beneficiaries within participating WISH buildings
  3. $8.8 Million Medicare Savings  
{title_0:text default="title 0"}
{content_0:content}
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.

Key Results:
  1. More than 950 people served with Nexus Montgomery Funds
  2. Two times the estimated value of services provided compared to the cost to the program
  3. Achieved an 85% referral-to-appointment rate
{title_0:text default="title 0"}
{content_0:content}
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.

Key Results:​
  1. 13,260 Severely Mentally Ill Patients Served
  2. 149 ACT Team Cases & 549 Crisis House Admissions
  3. $4.2 Million in Total Cost of Care of Savings Generated from Crisis House Expansion
{title_0:text default="title 0"}
{content_0:content}
Active Programs

View the on-going programs that spur improved care for the most vulnerable patients in Montgomery County.
Team

Meet the people behind the scenes who run the Nexus Montgomery programs.
​
About   Team  Partners  Programs  News   Connect