Despite having some of Maryland’s best health outcomes and a comprehensive set of community resources available to its residents, Montgomery County has many disparities across its 81 ZIP codes. To address some of them, the Nexus Connect Program piloted pathways to community resources in a hyper-targeted region of the County: ZIP codes 20877 (Gaithersburg) and 20886 (Montgomery Village).
PCC and our partners strove to connect 1,000 residents of the area to resources within their immediate community over the two-year initiative. By June 2024, we had done just that.
Program Structure
With grant funding from the Maryland Community Health Resources Commission (CHRC)*, the program focused on five main pillars of access to address social determinants of health impacting community members: access to primary care, health education & disease management, food insecurity, financial assistance, and early childhood education.
• Initial outreach: PCC partnered with Cross Community to conduct outreach within the service area and participate in large community events where their Justice, Equity, Diversity, and Inclusion (JEDI) staff would conduct social determinants of health (SDOH) screenings. In the second year, HealthPro health promoters were brought onboard to increase program reach and screen additional residents across both zip codes.
• Assistance with food and daily needs: Gaithersburg Help, a local organization focused on addressing basic needs, provided access to their food pantry in addition to infant care, daily use items, and prescription assistance. Cross Community also provided regular food and diaper distributions.
• Tools for healthy development: The Montgomery County Collaboration Council for Children, Youth, and Families (MCCC) provided The Basics program, an early childhood education resource for parents of children under five.
• Financial help via tax-prep support: Cross Community also ran an annual Volunteer Income Tax Assistance (VITA) clinic, which offers free tax preparation services to low-income residents, as well as those who are elderly, disabled, or may have limited English proficiency. As the County VITA information notes, there are state, federal, and local tax credits available for residents below a household income threshold, as well as credits based on dependent children, occupation, and living situation.
• Health management and care navigation: Holy Cross Health community health workers (CHWs) facilitated follow-up navigation for any program participant in need of connection to primary care services, health insurance, or health education.
• Implementation oversight: The Nexus Montgomery Regional Partnership (NMRP)—a collaborative of the hospital systems in Montgomery County focused on lowering total cost of care and positively impacting population health across the region—monitored program progress.
Key findings
The majority of community members screened were living at or below 200% of the federal poverty line—pegged at $62,400 in 2024 for a family of four—and faced challenges accessing healthcare and meeting social needs. By June 2024, over 170 parents were enrolled in The Basics program, and Cross Community had supported 50 families with their taxes. Over 400 participants had received food services, and another 270 had been connected to diapers, formula, and other daily-use items.
Over 300 participants screened positive for either prediabetes or hypertension and over half of these participants were enrolled in health education and chronic disease management programs at Holy Cross Health, such as Road to Health and the Diabetes Prevention Program (DPP).
At the time of screening, well over half of all Nexus Connect participants reported that they did not have a primary care provider or health insurance coverage. The program was designed to make an immediate connection to primary care at the Gaithersburg safety-net clinic that offers preventive check-ups, connection to specialty care, and medical coverage for those deemed uninsurable.
A potential success of the Nexus Connect program was its grouping of affordable health and preventive care access within a package of basic needs, and its leveraging of hospital partnership data to assess impact. While the total cost per person screened was less than $375, the ability to measure changes in potentially avoidable emergency department utilization over time allows PCC to estimate a return on that community investment. Final evaluation on this measure is still pending because of the lag in hospital data availability through the Chesapeake Regional Information System for our Patients (CRISP). As of December 2023—three-quarters of the way through the pilot—non-emergency hospital use had declined by 11.55% from baseline in six high-need census tracts within the target ZIP codes.
The Takeaway
The Nexus Connect program demonstrated a model for SDOH screenings and tailored social services for underserved communities in Montgomery County. PCC strives to ensure that all residents have equitable access to healthcare and social resources that will allow them and their families to thrive. Ensuring that access requires cross-sector partnerships and benefits from groundwork by community health workers; both elements need more systematic support.
*Supported by the Maryland Community Health Resources Commission. The views presented here are those of the author and not necessarily those of the Commission, its Commissioners, or its staff.
PCC and our partners strove to connect 1,000 residents of the area to resources within their immediate community over the two-year initiative. By June 2024, we had done just that.
Program Structure
With grant funding from the Maryland Community Health Resources Commission (CHRC)*, the program focused on five main pillars of access to address social determinants of health impacting community members: access to primary care, health education & disease management, food insecurity, financial assistance, and early childhood education.
• Initial outreach: PCC partnered with Cross Community to conduct outreach within the service area and participate in large community events where their Justice, Equity, Diversity, and Inclusion (JEDI) staff would conduct social determinants of health (SDOH) screenings. In the second year, HealthPro health promoters were brought onboard to increase program reach and screen additional residents across both zip codes.
• Assistance with food and daily needs: Gaithersburg Help, a local organization focused on addressing basic needs, provided access to their food pantry in addition to infant care, daily use items, and prescription assistance. Cross Community also provided regular food and diaper distributions.
• Tools for healthy development: The Montgomery County Collaboration Council for Children, Youth, and Families (MCCC) provided The Basics program, an early childhood education resource for parents of children under five.
• Financial help via tax-prep support: Cross Community also ran an annual Volunteer Income Tax Assistance (VITA) clinic, which offers free tax preparation services to low-income residents, as well as those who are elderly, disabled, or may have limited English proficiency. As the County VITA information notes, there are state, federal, and local tax credits available for residents below a household income threshold, as well as credits based on dependent children, occupation, and living situation.
• Health management and care navigation: Holy Cross Health community health workers (CHWs) facilitated follow-up navigation for any program participant in need of connection to primary care services, health insurance, or health education.
• Implementation oversight: The Nexus Montgomery Regional Partnership (NMRP)—a collaborative of the hospital systems in Montgomery County focused on lowering total cost of care and positively impacting population health across the region—monitored program progress.
Key findings
The majority of community members screened were living at or below 200% of the federal poverty line—pegged at $62,400 in 2024 for a family of four—and faced challenges accessing healthcare and meeting social needs. By June 2024, over 170 parents were enrolled in The Basics program, and Cross Community had supported 50 families with their taxes. Over 400 participants had received food services, and another 270 had been connected to diapers, formula, and other daily-use items.
Over 300 participants screened positive for either prediabetes or hypertension and over half of these participants were enrolled in health education and chronic disease management programs at Holy Cross Health, such as Road to Health and the Diabetes Prevention Program (DPP).
At the time of screening, well over half of all Nexus Connect participants reported that they did not have a primary care provider or health insurance coverage. The program was designed to make an immediate connection to primary care at the Gaithersburg safety-net clinic that offers preventive check-ups, connection to specialty care, and medical coverage for those deemed uninsurable.
A potential success of the Nexus Connect program was its grouping of affordable health and preventive care access within a package of basic needs, and its leveraging of hospital partnership data to assess impact. While the total cost per person screened was less than $375, the ability to measure changes in potentially avoidable emergency department utilization over time allows PCC to estimate a return on that community investment. Final evaluation on this measure is still pending because of the lag in hospital data availability through the Chesapeake Regional Information System for our Patients (CRISP). As of December 2023—three-quarters of the way through the pilot—non-emergency hospital use had declined by 11.55% from baseline in six high-need census tracts within the target ZIP codes.
The Takeaway
The Nexus Connect program demonstrated a model for SDOH screenings and tailored social services for underserved communities in Montgomery County. PCC strives to ensure that all residents have equitable access to healthcare and social resources that will allow them and their families to thrive. Ensuring that access requires cross-sector partnerships and benefits from groundwork by community health workers; both elements need more systematic support.
*Supported by the Maryland Community Health Resources Commission. The views presented here are those of the author and not necessarily those of the Commission, its Commissioners, or its staff.
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