For the Health of the Community
Date: July 1, 2013
Employees across Johns Hopkins Medicine have been busy the past several months implementing a new program to improve care coordination for patients in or near East Baltimore.
The Johns Hopkins Community Health Partnership—launched last year with a $19.9 million, three-year “innovation grant” from the Centers for Medicare & Medicaid Services—seeks to improve quality of care and health for community residents while preventing unnecessary, costly hospital readmissions and Emergency Department visits.
The program initially is focusing on helping frequent users of hospital care in East Baltimore and patients hospitalized on certain units at The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center. Plans call for nearly all adult inpatients at those hospitals, along with an estimated 3,000 community members deemed as high risk for hospitalization—2,000 Medicare Fee-for-Service beneficiaries and 1,000 Priority Partners Medicaid Managed Care beneficiaries—to reap the program’s benefits by July 2015. Many targeted patients have chronic illness, mental health needs and/or a history of substance use disorder.
Inside the hospital, health care teams comprising pharmacists, physical therapists, case managers, nurses and physicians form individualized care plans. Patients and caregivers can learn to manage their health conditions via computer tablet courses. After discharge, transition guides and community health workers help support patients and pay home visits to those at risk for rehospitalization.
The Community Oversight Committee—headed by Linda Dunbar, vice president of population health and care management for Johns Hopkins HealthCare; Ray Zollinger, regional medical director of Johns Hopkins Community Physicians; and Johns Hopkins internist/epidemiologist J. Hunter Young—has been hard at work since January.
Traditional patient-centered medical home models have difficulty engaging patients in urban environments, Young says. Many of these patients frequent the Emergency Department because they don’t know how or are unable to connect to primary care. Wanting to support patients where they live, Johns Hopkins HealthCare has hired 10 of a projected 30 allied health professionals from East Baltimore to serve as community health workers, locating patients at high risk for hospitalization, engaging them in the program and breaking down their barriers to care. They meet some patients in the hospital before discharge and target others at home.
With the help of iPads outfitted with case-management software, workers document their efforts, communicate with supervisors, and map where patients live to more efficiently plan their day. About half of the 300 patients contacted so far have enrolled in the program, which aims to reach 700 more patients by year’s end. The software allows supervisors to track how many and what types of outreach efforts have been used.
“We’ve had very good success in locating and engaging patients,” Young says. “Patients often feel very comfortable talking with the community health workers because they share common backgrounds.”
Adds Dunbar, “They really do everything from helping schedule appointments with a primary care provider, to getting on a bus and accompanying patients to the clinic to going grocery shopping for healthy food.”
One woman with a young son told her community health worker that she really wanted to enroll in a substance use treatment program but always found barriers to doing so, Dunbar says. The worker helped the woman schedule an intake appointment with a local program, then accompanied her there on public transportation. “We’re starting to make a dent in getting patients into the right treatments.”
Another novel aspect involves placing nurse case managers and behavioral specialists like counselors and social workers in primary care clinics at East Baltimore Medical Center, the comprehensive care practice at Bayview, and the general internal medicine clinics at Bayview and the Johns Hopkins Outpatient Center to address the mental health, behavioral health or substance use issues affecting at least 30 percent of patients.
Residents in parts of East Baltimore live 20 years less than those in Baltimore’s Roland Park neighborhood, says Zollinger: “Every disease that kills people, these folks have more of it.”
What’s most exciting, he says, is that the program “will have a significant impact on the health of the residents of this community.”