Overview

Johns Hopkins Community Health Partnership (J-CHiP) is a three-pronged care coordination program with comprehensive community support for a cohort of high-risk patients, enhanced discharge procedures for all adults in the acute care setting, and improved prevention of rehospitalization among a set of skilled nursing centers, aiming to decrease readmission rates and improve coordination for high-risk patients.

In collaboration with Healthcare: The Journal of Delivery Science and Innovation

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Organization Name

Johns Hopkins Medicine

Organization Type
  • Academic Hospital
  • Community health center
  • Community organization
  • FQHC
  • Skilled nursing facility
National/Policy Context

  • Johns Hopkins Medicine (JHM) and its associated partners are serving an increasingly medically and socially complex urban population.
  • Numerous structural barriers, such as a lack of interprofessional communication, frequent patient readmission to the hospital, a lack of community-based health education and resources, and historical and social barriers to healthcare use prevent optimal delivery of healthcare services to these populations.

Local/Organizational Context

  • JHM was the primary organization responsible for implementation of the project, but community-based organizations played a vital role in its success.
  • Several skilled nursing facilities and other smaller community organizations were also included. This required the cooperation of the leaders of several distinct organizations.
  • The full list of organizations involved includes:
    • Johns Hopkins Hospital (JHH)
    • Johns Hopkins Bayview Medical Center (JHBMC)
    • Johns Hopkins Community Physicians, Sisters Together and Reaching (STAR)
    • Men and Families Together (MFC)
    • Five associated skilled nursing facilities

Patient Population Served and Payor Information

Johns Hopkins serves a diverse urban population, and this project has a focus on underserved Medicaid and Medicare beneficiaries.

Leadership

The program was coordinated by JHM leadership but involved community partners, skilled nursing facilities, outpatient clinics, and inpatient wards.

Funding

Funding was garnered via a Health Care Innovation Award (HCIA) from the Center for Medicare and Medicaid Innovation (CMMI).

Research + Planning

  • J-CHiP targeted approximately 3,000 high-risk Medicare and Medicaid beneficiaries who receive their primary care at outpatient clinics associated with the Johns Hopkins Medicine healthcare systems. It also targeted approximately 40,000 adults admitted to the two Johns Hopkins teaching hospitals each year.
  • The nature of the HCI award necessitated a rapid, full-scale roll-out rather than a gradual, phased approach.

Tools or Products Developed

  • Barriers-to-care assessments, which identified challenges patients faced in accessing transportation to and from health-related appointments, social and financial circumstances, and communication barriers, were conducted for each high-risk patient and used to select targeted interventions for individuals in the community.
  • The “bridge to home” discharge process for patients in the acute care setting included screening to predict post-discharge needs, tablet-based modules and teach-back to enhance patient education, medication management including provision of certain medications at discharge, nurse-driven telephonic follow-up, and home care and monitoring for high-risk patients.
  • A unique set of protocols for frequent causes of rehospitalization and long term sequelae (e.g. delirium, antibiotic use) were implemented in skilled nursing facilities that received many patients discharged from the acute setting.

Training

  • The CMMI grant provided funding for hiring and training of over 75 new employees and retraining of many more.
    • Community Health Workers (CHWs), Neighborhood Navigators (NNs; residents of involved communities who coordinate community organizations, outreach, and connect patients with necessary resources), case managers, and other clinical staff were trained to perform the assessments and provide community interventions/resources.
    • Training was provided for inpatient units in the “bridge to home” system and Transition Guides, who were nurses who conducted home visits and phone visits in the 30 days post-discharge.
    • J-CHiP sponsored a geriatric nurse educator to train those in skilled nursing facilities to document rehospitalization rates and other data and deploy interventions (e.g. protocol for delirium patients).

Tech Involved
  • Care coordination system
Team Members Involved
  • Behavioral Health Specialist
  • Community Health Worker
  • Neighborhood Navigator
  • Primary Care Physicians
  • Social Worker
Workflow Steps

  • Patients in the high-risk category were assigned an integrated team of PCPs, CHWs, NNs, case managers, and health behavior specialists.
    • Each high-risk patient was initially contacted by a CHW, who conducted a thorough in-home “barriers to care” assessment.
    • Following the at-home assessment, a care management assessment was conducted at the patient’s clinical site to determine demographic, clinical, and health history.
    • Care plans were created using the two assessments.
  • Each patient’s care plan was reviewed during rounds by the interdisciplinary team, and teams then deployed a set of community resources, health habits improvements, and programs to support patients with chronic disease or behavioral health needs.
    • J-CHiP provided transportation support (e.g. bus tokens and cab/shuttle support), social work intervention, pharmacy assistance programs, and pre-programmed cell phones to contact healthcare team members to mitigate these barriers.
  • A team of CHWs and NNs was implemented in high-need regions to carry out home visits, education, outreach and connection to resources, support groups, and other community interventions.
  • All adults in the acute care setting where units have adopted the “bridge to home” bundle of interventions were offered a tailored set of the available services pre- and post-discharge.
  • The five skilled nursing facilities that received the majority of discharged patients from JHM hospitals were trained in programs to reduce causes of rehospitalization and track data on patient outcomes.

Budget
  • >$1M
Budget Details

  • Funding for this program came from numerous sources, though the primary funding was from the Health Care Innovation Award (HCIA) from the Center for Medicare and Medicaid Innovation (CMMI).
  • Undisclosed additional funding from the institutions involved was required.
  • Approximately 1,000 of the high-risk patients were Priority Partners Managed Care Organization (PPMCO) Medicaid patients, whose care coordination costs were covered by institutional investments.

Where We Are

J-CHiP is began in 2012 and is ongoing but is being transitioned beyond the initial three-year CMMI award.

Outcomes

  • J-CHiP decreased healthcare costs and utilization for certain high-risk groups.
    • For Medicaid patients in the high-risk group, aggregate total cost of care (TCOC) decreased by $24.4 million and reductions in their hospitalizations, emergency department (ED) visits, 30-day readmissions, and avoidable hospitalizations were 33, 51, 36, and 7 per 1000 enrollees, respectively.
    • For Medicare patients in the high-risk group, per patient costs decreased modestly, but utilization was similar or higher.
  • The acute care interventions (“bridge to home” and skilled nursing interventions) led to a decreased aggregate TCOC of $29.2 million for Medicare patients and $59.8 million for Medicaid patients in comparison to matched controls.
    • Practitioner follow-up visits were reduced by 41 (7-day) and 29 (30-day) per 1000 Medicare beneficiary-episodes and 70 (7-day) and 182 (30-day) per 1000 Medicaid beneficiary-episodes,
    • While 90-day hospitalizations increased for both Medicare and Medicaid patients and 30-day readmission rates increased for Medicare patients, the 90-day ED visit rate decreased by 133 per 1000 episodes for Medicaid beneficiaries,
  • Cost savings for the entire program were estimated at $113.3 million

Future Outcomes

Additional metrics that take into consideration the lack of truly matched controls, data capture challenges, staggered and incomplete implementation of the program, and other factors are being investigated.

Benefits

  • Overall, the J-CHiP program decreased costs for JHM among those who were enrolled
  • Decreased utilization of healthcare was observed in Medicaid patients in the high-risk category and in select outpatient practitioner visits for both Medicare and Medicaid patients in the acute care interventions
  • The increases in utilization for Medicare patients in the high-risk groups and in hospital utilization for both Medicare and Medicaid patients in the acute care intervention highlight room for improvement in future iterations of the program

Unique Challenges

  • Development of an integrated information technology system to capture data and track patients is still ongoing and poses a barrier to accountable coordination.
    • Additionally, regulations on data sharing and a lack of shared EMR led to challenges in data-sharing, analysis, and intervention referral.
  • Promoting community engagement was challenging, particularly in areas with historical and systemic barriers to utilization of healthcare, and is ongoing through community interventions and engagement of community-based organizations.
    • A community advisory board and recruitment of NNs and CHWs from the communities they served improved these relationships.
  • J-CHiP sought to engage non-clinical team members to mitigate some of the challenges posed by extensive time demands on physicians and other clinical team members.
  • Academic medical center culture may have made implementation of interdisciplinary team rounds more difficult.
  • Traditional metrics such as 30-day readmission rates may not reflect patients who do not require hospitalization in the first place due to interventions.

Sources

  • Berkowitz, Scott A., et al. “Case Study: Johns Hopkins Community Health Partnership: A Model for Transformation.” Healthcare, vol. 4, no. 4, 29 Sept. 2016, pp. 264–270., doi:10.1016/j.hjdsi.2016.09.001.
  • Berkowitz, Scott A., et al. “Association of a Care Coordination Model With Health Care Costs and Utilization.” JAMA Network Open, vol. 1, no. 7, 2018, doi:10.1001/jamanetworkopen.2018.4273.
  • Murphy, Shannon M.e., et al. “Going Beyond Clinical Care to Reduce Health Care Spending.” Medical Care, vol. 56, no. 7, 2018, pp. 603–609., doi:10.1097/mlr.0000000000000934.
  • CMS Funding: https://innovation.cms.gov/initiatives/Health-Care-Innovation-Awards/Maryland.html

Editors
  • Katherine Rowe, BA
Location

Baltimore, MD

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