The Nexus Montgomery Regional Partnership is turning 10 in July! That’s a decade of shared hospital investments in our community to achieve impact that no hospital could on its own: from patient navigation to quality improvement to county-wide system coordination. Shifting Medicaid eligibility rules and changing reimbursement structures have created an uncertain operating climate for hospitals, but they have continued to invest in this partnership potential.
With the Primary Care Coalition (PCC) as its management entity and staffing infrastructure, Nexus Montgomery serves as a vital collaborative platform for Montgomery County hospitals, community partners, and public-sector leaders to address shared health system challenges. Nexus helps strengthen care coordination, improve outcomes, and generate measurable value by bringing organizations to the same table—and its shared support system. Over the past year alone, Nexus Montgomery has advanced several key initiatives that demonstrate the power of partnership and data-driven action.
Strengthening Transitions from Hospital to Skilled Nursing Care
One of Nexus Montgomery’s longest-running and most successful efforts is the Skilled Nursing Facility Alliance. Through sustained quality improvement, hospital-facility collaboration, and targeted data-driven interventions, the Alliance has helped reduce rehospitalizations and improve transitions of care. The program continues to support safer, more coordinated care for patients while delivering a strong return on investment for partner hospitals.
Building the Health Care Workforce Pipeline
PCC’s Workforce Capacity Program is also helping to prepare Montgomery County residents for careers in health care. From 2023 through 2025, PCC supported 226 residents with Certified Nursing Assistant (CNA) scholarships, job-readiness training, employment navigation, and wraparound services. Many participants are also continuing their career pathways through the successful Bridge to Nursing program, creating new opportunities for local residents while helping address critical workforce needs.
Addressing Complex Discharge Challenges
Nexus Montgomery has also convened a growing coalition focused on patients who remain hospitalized after they are medically cleared for discharge. These “hard-to-place” patients often face complex barriers that require coordination across hospitals, county agencies, state partners, and community organizations. Nexus has helped move this work forward through leadership collaboratives and focused workgroups designed to improve discharge pathways, care transitions, and system-level solutions.
Improving Behavioral Health Coordination
Behavioral health remains another area where Nexus is helping partners coordinate more effectively. By using data from sources such as 911 calls and CRISP, Nexus has supported efforts to identify and better serve high utilizers of behavioral health services. Its partnership with Montgomery County Behavioral Health and Crisis Services has contributed to crisis system coordination, mobile crisis services, and 988 implementation.
A Trusted Convener for Montgomery County
Across Montgomery County and Maryland, Nexus Montgomery is recognized as a trusted convener that enables innovation and collaboration among hospital systems and public-sector partners. The Nexus Montgomery Board of Managers meets annually with the leadership from Montgomery County Department of Health and Human Services (DHHS), and many DHHS leaders serve on Nexus steering committees and workgroups. This work demonstrates how shared infrastructure can help organizations solve challenges that no single institution could address alone.
Looking Ahead: FY27 Priorities
In FY27, Nexus Montgomery will focus on three strategic priorities: aligning programs with Maryland’s AHEAD model and Population Health Accountability Plan; continuing work to improve throughput, utilization, behavioral health crisis coordination, and discharge pathways; and pursuing external funding to sustain and expand high-impact programs, including workforce capacity and patient navigation initiatives. The PCC team also works to socialize partnership results among a wider audience, showing state workgroups and organizations outside Montgomery County just how much is possible. Together, these efforts position Nexus Montgomery as high-value collaborative infrastructure for the region’s health care ecosystem. Through PCC’s continued support and partnership, Nexus Montgomery is helping hospitals, county agencies, and community partners improve care, address system pressures, and create healthier communities across Montgomery County.
With the Primary Care Coalition (PCC) as its management entity and staffing infrastructure, Nexus Montgomery serves as a vital collaborative platform for Montgomery County hospitals, community partners, and public-sector leaders to address shared health system challenges. Nexus helps strengthen care coordination, improve outcomes, and generate measurable value by bringing organizations to the same table—and its shared support system. Over the past year alone, Nexus Montgomery has advanced several key initiatives that demonstrate the power of partnership and data-driven action.
Strengthening Transitions from Hospital to Skilled Nursing Care
One of Nexus Montgomery’s longest-running and most successful efforts is the Skilled Nursing Facility Alliance. Through sustained quality improvement, hospital-facility collaboration, and targeted data-driven interventions, the Alliance has helped reduce rehospitalizations and improve transitions of care. The program continues to support safer, more coordinated care for patients while delivering a strong return on investment for partner hospitals.
Building the Health Care Workforce Pipeline
PCC’s Workforce Capacity Program is also helping to prepare Montgomery County residents for careers in health care. From 2023 through 2025, PCC supported 226 residents with Certified Nursing Assistant (CNA) scholarships, job-readiness training, employment navigation, and wraparound services. Many participants are also continuing their career pathways through the successful Bridge to Nursing program, creating new opportunities for local residents while helping address critical workforce needs.
Addressing Complex Discharge Challenges
Nexus Montgomery has also convened a growing coalition focused on patients who remain hospitalized after they are medically cleared for discharge. These “hard-to-place” patients often face complex barriers that require coordination across hospitals, county agencies, state partners, and community organizations. Nexus has helped move this work forward through leadership collaboratives and focused workgroups designed to improve discharge pathways, care transitions, and system-level solutions.
Improving Behavioral Health Coordination
Behavioral health remains another area where Nexus is helping partners coordinate more effectively. By using data from sources such as 911 calls and CRISP, Nexus has supported efforts to identify and better serve high utilizers of behavioral health services. Its partnership with Montgomery County Behavioral Health and Crisis Services has contributed to crisis system coordination, mobile crisis services, and 988 implementation.
A Trusted Convener for Montgomery County
Across Montgomery County and Maryland, Nexus Montgomery is recognized as a trusted convener that enables innovation and collaboration among hospital systems and public-sector partners. The Nexus Montgomery Board of Managers meets annually with the leadership from Montgomery County Department of Health and Human Services (DHHS), and many DHHS leaders serve on Nexus steering committees and workgroups. This work demonstrates how shared infrastructure can help organizations solve challenges that no single institution could address alone.
Looking Ahead: FY27 Priorities
In FY27, Nexus Montgomery will focus on three strategic priorities: aligning programs with Maryland’s AHEAD model and Population Health Accountability Plan; continuing work to improve throughput, utilization, behavioral health crisis coordination, and discharge pathways; and pursuing external funding to sustain and expand high-impact programs, including workforce capacity and patient navigation initiatives. The PCC team also works to socialize partnership results among a wider audience, showing state workgroups and organizations outside Montgomery County just how much is possible. Together, these efforts position Nexus Montgomery as high-value collaborative infrastructure for the region’s health care ecosystem. Through PCC’s continued support and partnership, Nexus Montgomery is helping hospitals, county agencies, and community partners improve care, address system pressures, and create healthier communities across Montgomery County.
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