A Collaborative Approach to Health Care | MedStar Health

A Collaborative Approach to Health Care

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In the video above, Alfredo Monterroso, a patient of MedStar Montgomery receives a home visit from nurse Evangeline Sison through the Care Transitions program.

Nexus Montgomery

In 2016, six hospitals operating in Montgomery County, Maryland, partnered with a network of community-based organizations to form the Nexus Montgomery Regional Partnership. It consists of four programs designed to improve the overall health of the community, increase people’s satisfaction with their health and health care, and encourage efficient health care spending. MedStar Montgomery Medical Center is working as part of Nexus Montgomery to reduce hospital readmission rates and improve coordination of healthcare delivery within the county.

“We all learn from each other, and it improves the overall quality of care,” explains Diana Saladini, director of Population Health and Outpatient Services at MedStar Montgomery and vice chair of Nexus Montgomery’s board of managers. “The Nexus Montgomery Regional Partnership allows us to see what works well, share methods across the partnership and MedStar, and learn from each other how to work better with our patients.”


Within the Partnership, the Care Transitions program identifies patients at the highest risk for hospital readmission and pairs them with a nurse for follow up. The nurses meet with patients, schedule doctor appointments, make sure patients receive their medications, ensure they have transportation to appointments, and follows up with them for 30 days after they are discharged from a hospital. Through the Partnership, Care Transitions reached more than 1,300 people in 2017.

Alfredo Monterroso, a patient who was hospitalized at MedStar Montgomery, says Care Transitions was crucial to his recovery, as was the nurse who worked with him once he got home and helped him follow his treatment plan.

“To be honest, without that program, I wouldn’t have been able to survive—it was that serious,” he says. “The program has made it easier for me to get my medication, as well as the oxygen tank I need to breathe.”

Specialty Care for the Uninsured

The Specialty Care for the Uninsured program was created in 2016 to provide funding for uninsured patients who need to see a specialist after discharge from the hospital. MedStar Montgomery worked with the Primary Care Coalition to give patients access to such services.

Wellness and Independence for Seniors at Home (WISH)

The largest program to launch as part of the Partnership was the Wellness and Independence for Seniors at Home (WISH) program in 2016, which provides health coaches to patients who are discharged from the hospital into independent living communities. The health coaches help patients with tasks from arranging transportation to ordering medical suppies. The expectations of the program are to help reduce seniors’ risk of readmission to a hospital.

Cornerstone Montgomery Mental Health Program

The most recent initiative launched by Nexus Montgomery, the Cornerstone Montgomery Mental Health Program, began in 2017. The program aims to expand access to behavioral health services. To meet the need for more mental health resources in the county, the participating Partnership members collaborated with Cornerstone Montgomery—the largest provider of behavioral health services in the county—to fund the creation of an eight-bed crisis house, including an outpatient case management team dedicated to patients who need behavioral health services.

The Partnership selected some of the most pressing needs and designed programs and services to proactively reduce unnecessary re-hospitalization, connect patients to supportive services, and expand access to specialty care and behavioral health services.

“We try to motivate patients to become engaged in their own care,” Saladini states. “Our goal is to provide them with the necessary programs, tools, education and support they need to avoid unnecessary hospital visits and to improve their overall health.”

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To learn more about MedStar Health's programs and initiatives across Maryland and the Washington, D.C., region that are contributing to healthier communities, contact Raquel Lamptey at 410-772-6910