Healthcare Innovation Awards: John Hopkins University

Abstract

Johns Hopkins University, in partnership with Johns Hopkins Health System and its hospitals, community clinics and other affiliates, the Johns Hopkins Urban Health Institute, Priority Partners MCO, Baltimore Medical System (BMS) – a Federally Qualified Health Center, and local skilled nursing facilities, received an award to create a comprehensive and integrated program, the Johns Hopkins Community Health Partnership (J-CHiP). J-CHiP is designed to increase access to services for high-risk adults in East Baltimore, MD, especially those with chronic illness, mental illness, and/or substance abuse conditions. The intervention improves care coordination across the continuum and comprises early risk screening, interdisciplinary care planning, enhanced medication management, patient/family education, provider communication, post-discharge support and home care services, including self-management coaching, and improved access to primary care. The program will target inpatients at The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, expanding to nearly all adult admissions by the end of year 3. The intervention will also include a specific focus on high risk Medicare and Medicaid beneficiaries who receive primary care from Johns Hopkins clinics and a BMS clinic adjacent to these hospitals. The program will reduce avoidable hospitalizations, emergency room use, and complications and increase access to care and other services. Over a three-year period, Johns Hopkins University will train and hire more than 75 new healthcare workers, including nurse educators, nurse transition guides, case managers, community health workers, and health behavior specialists, and will retrain care coordinators, patient access line case managers, clinical pharmacy specialists, community health workers, and physicians already on staff.