New in Nexus
Advanced Care Planning

Advanced care planning can improve quality of life by avoiding unwanted treatments at the end of life, decreasing the burden and increasing choice for patients and their families.        

In 2019, Nexus Montgomery will launch a community-wide initiative aimed at increasing the number of people who have considered their options for end of life care and made those wishes known to a family member or health care proxy. 

The Jewish Social Services Agency (JSSA) has been chosen by Nexus Montgomery to lead this important initiative. This summer, JSSA will engage with community partners to begin increasing advanced care planning activities in the Nexus community. Community partners will host advanced care planning education events. Next year, a broad community education campaign will be introduced and a “train-the-trainer” model with partners will be expanded.
Respite Care for the Homeless

Currently, there are no medical respite care beds for homeless individuals in Montgomery County. This means that homeless patients stay longer in the hospital than is medically necessary and have a higher risk for complications and readmission. 

Nexus Montgomery is partnering with Montgomery County Department of Health and Human Services to add these much needed medical respite beds for the homeless. This program would provide medical cost savings and improve the quality of life for this population.

Nexus will provide funding for construction and first-year operations. 15 medical respite care beds will be developed at a homeless shelter in Rockville, MD. Wrap around medical and social services will be provided by program staff.
Out-Patient Mental Health Clinic (OMHC)

Nexus is partnering with Vesta and Cornerstone Montgomery in Montgomery and Prince George’s County to improve access to OMHC care for behavioral health clients. The Nexus Behavioral Health Workgroup identified that structural inefficiencies prevent behavioral health patients from connecting to community-based treatment in a timely manner after a hospital encounter.

Nexus, Vesta, Cornerstone, and a consultant will partner to optimize the work being done in OMHC’s so that patients can get treatment the same day they are discharged from the hospital. This project will expand capacity by reducing wait times for services and increasing early access to treatment. Stakeholder follow up meetings between OMHC providers and hospitals will improve communication, and Nexus patients will have access to these OMHC’s. 
To learn more contact Maddy Nelson, Madeline_Nelson@PrimaryCareCoalition.org
Skilled Nursing Facility Alliance

Nexus Montgomery’s Skilled Nursing Facility (SNF) Alliance, launched in August 2017, brings together the 6 Nexus hospitals and 37 SNF providers to improve communication and collaboration among hospitals, SNFs and other post-acute care providers around a shared goal: improving the quality of patient care and reducing total cost of care.

Since the Alliance began, facilities have shared best practices, leveraged quality performance data, and planned and implemented quality improvement initiatives The partners continue to be fully committed to working together to improve the health of their shared population and manage health care costs primarily through reducing readmissions to the hospital.

To learn more about contact Bethany Sanders, Bethany_Sanders@PrimaryCareCoalition.org .

SNF Highlight: Cadia Healthcare
Cadia Healthcare has reduced its readmission rate across all three facilities by 27% at their Wheaton facility, 43% at their Hyattsville facility, and 62% at their Springbrook facility.
"
The SNF Alliance meetings have been a great source of information.

We've developed a closer bond with the hospitals, which provide consultations and access to medications. We've learned the best practices to keep our patients healthy, prevent rehospitalizations, and prevent unnecessary medical procedures.

Most importantly, we've learned how to better communicate with family members to plan the best course of action for our patients.
"
- Evette Matthews, Cadia Healthcare
Patient Testimonial
Wellness and Independence for Seniors at Home
Madeline is 81 years-old and has a number of health issues, including problems with her heart and her balance. Even with the love and support of her 10 siblings, four children and 25 grandchildren she needs the help of a health professional who understands her concerns.

Thanks to the WISH Program, she also now has a health coach who helps her remain healthy and independent by developing a health plan and connecting her to resources in the community.

Madeline has worked with her Health Coach, Tenisha, for a year. With Tenisha’s assistance, Madeline has been able to receive health services right in the comfort of her own home. Tenisha is also available when Madeline has emergencies and has to spend time in the hospital. After one of her hospitalizations, Tenisha made sure Madeline went to see her cardiologist and her primary care doctor so she could receive the follow up care she needed to avoid future hospitalizations. 

Madeline is truly thankful for the assistance she receives from her WISH health coach.

 
"
This is one of the best programs out there. It is nice to have the chance to talk to someone who you can be open and honest with and really express yourself.

Tenisha [my coach] goes above and beyond.
"
To learn more contact Susan Donovan, Susan_Donovan@PrimaryCareCoalition.org
Fast Facts
  • WISH has provided 1,279 care visits to clients

  • THE ASSERTIVE COMMUNITY TREATMENT (ACT) Team served 104 patients in the community experiencing a severe mental health episode

  • Since opening the Layhill CRISIS HOUSE has served 154 clients experiencing a mental health crisis.

  • PROJECT ACCESS has provided specialty care to 646 unique patients in 2,167 encounters.
Meet the Staff
Orlando Wright, Ph.D., LCSW-C - Behavioral Health Integration Manager
Orlando works to facilitate collaboration across Nexus hospitals, community-based organizations and the Core Services Agencies to optimize and develop behavioral health resources. He previously served as the Director of Behavioral Health for Catholic Charities of Greater Hartford and oversaw the Office of Pre-Trial Interventions for the State of Connecticut. He holds a Master of Social Work from the University of Connecticut and a PhD in the School of Behavioral and Social Science from Capella University.  
Katia Vlasova - Project Coordinator
Ekaterina “Katia” provides project management support for the Mental Health First Aid Training initiative as well as administrative support for Nexus leaders and the Board of Directors. Previously, she was a Thomas J. Watson Fellow and Health for America Fellow, where she carried out international fieldwork exploring the mind-body connection in contemplative communities and launched a novel toolkit-based patient education service, respectively. She holds a Bachelor of Arts in Biology from Bryn Mawr College.
Meet the Board of Managers
Annice Cody - Nexus Montgomery Board Chair
Annice Cody is the President of Holy Cross Health Network, Holy Cross Health's community-based operating division. Holy Cross Health Network operates four primary care safety-net health centers and two geriatric-focused primary care sites; provides more than 200,000 community health encounters annually through programs such as Senior Fit, perinatal education, Chronic Disease Self-Management and community health worker outreach; oversees Holy Cross Health's $60 million community benefit program; and leads Holy Cross Health's population health initiatives. 
 
Annice serves as the Board Chair for Nexus Montgomery Regional Partnership, a regional partnership among the six Montgomery County, MD hospitals focused on improving health in our community and reducing the demand for care and its associated costs.
 
Annice received an MBA from the Kellogg School of Management at Northwestern University and a BA from Brown University.