Nexus Montgomery Regional Partnership AN OVERVIEW A Unique

Nexus Montgomery Regional Partnership AN OVERVIEW

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 • Health. Care 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 • Med. Star Montgomery Medical Center 2

Six Hospitals. Four Systems. One Community. 3 • 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 https: //factfinder. census. gov/faces/nav/jsf/pages/community_facts. xhtml# Figure 1 US Census Data, 2010: Medicare beneficiaries for the NM RP ZIP codes described in section 1 a, geographic scope, Proposal for HSCRC 3

Nexus Hospitals & Board of Managers Annice Cody President Holy Cross Health Network Yancy Phillips, MD Chief Quality Officer Holy Cross Health Monique Sanfuentes Director of Community Health & Wellness Suburban Hospital Johns Hopkins Medicine 4 Daniel Cochran Vice President Chief Financial Officer Chief Operating Officer Adventist Health Care, Shady Grove Medical Center Diana Saladini Director of Population Health & Outpatient Services Med. Star Montgomery Medical Center Marta Brito Perez Senior Vice President of Population Health Washington Adventist Hospital

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

A Partnership of Hospitals and Community Organizations Partnership Infrastructure * NMRP Board of Managers *Managed by: 9 November 2016 6 Partnership Program Intervention Committee HCT Learning Collaborativ e Partner Resources SNF Alliance Work Groups Finance Committee

7 Nexus Programs Wellness and Independence for Seniors at Home (WISH) Goal Hospital Care Transitions Stabilize health of older Improve transitions from adults to increase hospital-to-home community tenure Medicare beneficiary, 65+, live High to moderate risk of rein an Independent Living Facility admission Eligible High to moderate risk of Population potentially avoidable utilization High utilizers within 120 days Services Offered 7 Health coach with navigation to Hospital-based Care transition community support services 7 Uninsured / Project Access Severely Mentally Ill / Behavioral Health Connect uninsured to specialty care Improve community based resources for severely mentally ill 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 Specialty care visits scheduled by a Expanded Crisis House capacity case manager New Assertive Community Connection to community-based Low or no patient responsibility Treatment Team (ACT) services Behavioral Health Integration Manager

Social determinants of health Aligned Incentives 48% shared readmissions Maryland Waiver 8 Willingness Collaborati on

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

Behavioral Health Integration In A Value-Based Environment Potentially avoidable hospitalizatio ns Timely Access to Services Reducing readmission s Data sharing