1. Nexus Montgomery Regional Partnership
An overview

2. A Unique Partnership
Nexus Montgomery, LLC, a unique partnership of all six hospitals in Montgomery County, Maryland, is focused on improving health in our community and reducing the demand for care and its associated costs
Serves the residents of 47 ZIP codes in Montgomery and Prince George’s Counties
Initially funded through a grant from the Maryland Health Services Cost Review Commission (HSCRC)
Participating hospitals represent four health systems
Adventist Health Care
HealthCare Shady Grove Medical Center
Washington Adventist Hospital
Holy Cross Health (Trinity)
Holy Cross Hospital
Holy Cross Germantown Hospital
Johns Hopkins Health
Suburban Hospital
Medstar Health
MedStar Montgomery Medical Center 2

3. Six Hospitals. Four Systems. One Community.
Nexus hospitals have overlapping patient populations, including high-utilizing patients, and primary care referral sources
Serve 1.3 million diverse residents in Montgomery and Prince Georges counties i
Partnership with the Primary Care Coalition and other community-based organizations
Targeting four high-risk and high-cost populations
Partnership inspires ongoing evaluation of current and new collaborative opportunities
i U.S. Census Bureau, 2010: Community Facts. Retrieved June 26, 2017, from
Figure 1 US Census Data, 2010: Medicare beneficiaries for the NM RP ZIP codes described in section 1a, geographic scope, Proposal for HSCRC
Nexus Montgomery is a unique partnership:
All Hospitals in a single geography; representing four hospital systems.
Overlap of high utilizing patients – significant crossover of hospital usage among patients 3

4. Nexus Hospitals & Board of Managers
Daniel Cochran
Vice President
Chief Financial Officer
Chief Operating Officer
Adventist Health Care, Shady Grove Medical Center
Annice Cody
President
Holy Cross Health Network
Yancy Phillips, MD
Chief Quality Officer
Holy Cross Health
Diana Saladini
Director of Population Health & Outpatient Services
MedStar Montgomery Medical Center
Monique Sanfuentes
Director of Community Health & Wellness
Suburban Hospital Johns Hopkins Medicine
Marta Brito Perez
Senior Vice President of Population Health
Washington Adventist Hospital
Our Board of Managers is comprised of a representative from each hospital. The Board meets monthly and is further supported by:
P-PIC – Partnership Programs Intervention Committee
Finance Committee 4

5. Nexus Montgomery Regional Partnership
Holy Cross Germantown Hospital
MedStar Montgomery Medical Center
Shady Grove Adventist Hospital
Suburban Hospital
Holy Cross Hospital
Washington Adventist Hospital
Shaded area indicates NMRP service area. 5

6. A Partnership of Hospitals and Community Organizations
NMRP Board of Managers
Partner Resources
Partnership Program Intervention Committee
HCT Learning Collaborative
SNF Alliance
Work Groups
Finance Committee
Infrastructure *
Partnership
*Managed by:
Board with senior representation from each hospital
Program and finance committees meet monthly
P-PIC, in addition to program oversight, has several subgroups including the learning collaborative, SNF alliance, and ad-hoc workgroups
PCC as the management entity works with each level as well as with community partners and hospital staff
Nexus partners with PCC, Cornerstone, TCC, as well as with hospital care transition teams, and others, to support program implementation and development
PCC and Nexus also work closely with DHMH, HOC, DHHS, and other government and non-government partners to identify potential areas for partnership
9 November 2016 6

7. 7
Nexus Programs
Wellness and Independence for Seniors at Home (WISH)
Hospital Care
Transitions
Uninsured / Project Access
Severely Mentally Ill / Behavioral Health
Goal
Stabilize health of older adults to increase community tenure
Improve transitions from hospital-to-home
Connect uninsured to specialty care
Improve community based resources for severely mentally ill
Eligible Population
Medicare beneficiary, 65+, live in an Independent Living Facility
High to moderate risk of potentially avoidable utilization within 120 days
High to moderate risk of re- admission
High utilizers
Uninsured and without coverage eligibility
Prior hospital interaction within 60 days with referral for specialty care
Behavioral Health diagnosis and in crisis, or Severe Mental Illness diagnoses
High utilizers; high risk of PAU
Services Offered
Health coach with navigation to community support services
Hospital-based Care transition services
Connection to community-based services
Specialty care visits scheduled by a case manager
Low or no patient responsibility
Expanded Crisis House capacity
New Assertive Community Treatment Team (ACT)
Behavioral Health Integration Manager 7

8. Aligned Incentives Willingness Collaboration Social determinants
Maryland Waiver
Social determinants
of health
Aligned Incentives
Willingness
48% shared readmissions
Collaboration 8

9. Nexus Behavioral Health Workgroup
County
Community Providers
CRISP
MCO/Beacon
STEER program/Opioid Intervention Team
MoCo Healthcare for the homeless
MoCo EMS
Prince George’s CCCT
Clients
Opportunity

11. Behavioral Health Integration In A Value-Based Environment
Potentially avoidable hospitalizations
Reducing readmissions
Data sharing
Access to Services
Timely Access