Nexus Montgomery Launches SNF-to-Home Pilot to Improve Patient Transitions, Reduce Re-Hospitalizations

The steady march toward value-based care has encouraged providers across the continuum to get creative about patient care, especially when it comes to reducing avoidable hospital readmissions and improving the discharge process.

One of the latest examples of an innovative cross-continuum partnership is spearheaded by Nexus Montgomery, a collaboration between six competing Maryland hospitals that also works with local post-acute care providers, including more than three dozen allied skilled nursing facilities (SNFs).

“Nexus Montgomery is a collaborative that has a number of areas in which it is working,” Leslie Graham — president and CEO of the Primary Care Coalition, the management entity behind Nexus Montgomery — told Home Health Care News. “Out of our SNF Alliance [initative], we’ve launched a new SNF-to-home pilot.”


Launched Sept. 10, the overarching goal of the SNF-to-home pilot is to leverage non-medical home care to keep patients living safely and independently at home.

Broadly, here’s how it works: After a patient is discharged from one of Nexus Montgomery’s six hospitals and into an allied SNF, he or she is then connected with a non-medical home care provider that takes point on the eventual transition back home. Currently, those home care services are provided by either Silver Spring, Maryland.-based Family & Nursing Care or Adventist HealthCare Home Assistance.

“The SNF identifies eligible patients based on certain criteria, though they’re given the option whether or not to participate,” Graham said. “While that patient is still in the SNF, the home care agency meets with the patient and becomes part of the discharge planning process, which could even include arranging for transportation back home.”


In addition to transportation home, caregivers from Family & Nursing Care and Adventist HealthCare Home Assistance also work to make sure discharged patients have food in their pantries and the proper medication in stock.

They likewise ensure the home is free from potential fall hazards.

“When patients are discharged from rehab, they are incredibly vulnerable,” Mitch Markowitz, vice president of business development for Family & Nursing Care, told HHCN. “Oftentimes, these patients have been in the hospital for several weeks, then at a rehab community for several more.”

Constant change

With a team of about 1,200 caregivers serving hundreds of clients each day, Family & Nursing Care is one of the largest private-pay home care companies in the Washington, D.C., area.

Its 50-year-old history makes it one of the oldest home care providers in the region as well.

While Nexus Montgomery’s SNF-to-home pilot is good for patients migrating from hospital to SNF and back into the home, it’s equally a positive for Family & Nursing Care, according to Markowitz.

“One of the biggest ways this helps our business is that it keeps us engaged with the broader health care system,” he said. “We can support each other as we all collectively learn what the evolution of today’s health care industry really means. It’s changing constantly.”

For home care providers, much of that change includes a sudden rise to prominence over the past few years, a point punctuated by non-medical home care’s inclusion in the Medicare Advantage program.

In the past, home care was often seen as a luxury service for wealthier older adults, Markowitz said. Now, it’s seen as an essential service with a proven track record.

“We finally feel we’re at a place where private-duty home care is able to provide more support, do more for the greater good than we ever have before,” he said. “We want to help everybody, and partnerships like [Nexus Montgomery’s SNF-to-home pilot] are one of the ways we can get the word out there to help.”

Throughout the U.S. hospitals are subject to financial penalties when they experience high readmission rates. In Maryland, though, hospitals operate with an added wrinkle — a special waiver that has existed since the 1970s allowing the state to set its own reimbursement rates.

Creative partnerships like Nexus Montgomery have popped up partly because of that waiver, Markowitz said.

“The agreement was that we could keep this waiver as long as our spending was better than the national average,” he said. “That started to slip a few years ago, so the folks in Maryland who represent the hospital system said we’re going to turn the entire reimbursement system around. We switched to a population-health model, with fixed budgets for every single hospital across the state.”

“Instead of wanting to have more volume come through the hospitals, it made more sense for hospitals to keep people safe at home,” Markowitz added.

Home health connections

As its core, the Nexus Montgomery SNF-to-home pilot will help fill critical gaps in care when a patient is discharged from a SNF, goes home and waits for home health services to possibly begin.

Data collected by Nexus Montgomery shows that only 16% of discharged patients receive home health services within 48 hours of being sent home.

That’s an important statistic because the 30-day readmission rate is much higher for those patients, Susan Donovan, managing director for Nexus Montgomery, told HHCN.

“There’s this brief window immediately post-SNF discharge to home when home health wasn’t able to get in there,” Donovan said. “That’s a critical window, especially when it comes to addressing acute social needs.”

Right now, the SNF-to-home pilot is planned for a six-month testing period.

But if results are promising, it could be expanded.

“With this pilot, there’s really no gap in care after somebody leaves the SNF and goes home,” Temi Oshiyoye, quality improvement manager for Nexus Montgomery, told HHCN. “There’s somebody coming in and care can seamlessly continue.”

The Nexus Montgomery family of hospitals includes Adventist HealthCare Shady Grove Medical Center, Adventist HealthCare White Oak Medical Center, Holy Cross Hospital, Holy Cross Germantown Hospital, MedStar Montgomery Medical Center and Suburban Hospital.

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