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Care Coordination Model

The JHM care coordination model provides a comprehensive and patient-centered approach to improving care for our Medicare Fee-for-Service beneficiaries in the primary care setting. The care coordination model was developed with the following guiding principles in mind:

  • Deliver evidence-based care coordination interventions

  • Deliver care via a patient-centered and flexible care model in the least resource- intensive setting

  • Support seamless integration of care across the care continuum

  • Maximize primary care practice presence of care team members

  • Create a framework for structured coordination between providers and care team members

  • Ensure accountability of outcomes among all care team members

Our Care Team

JMAP’s goal is to provide health care that is custom-built for each patient. Within our care coordination model, we provide access to the following care team members for patients, based on their individual needs, with the goal of achieving higher quality and higher value health care for our Medicare Fee-for-Service beneficiaries.

  • Care Managers

    JMAP care managers are nurses and licensed certified and clinical social workers, most with many years of experience in more conventional health care settings. They provide a variety of patient-centered services. These include partnering with patients to make individualized care plans; ensuring that all needs are met during care transitions (e.g., hospital discharge); and, at times, arranging for transportation to and from appointments and accompanying patients to appointments. Read more about their amazing work with real JMAP patients on our testimonials page. Care managers are located at specific sites in the care continuum and are available for any patients who qualify for these services.

  • Health Behavioral Specialists (HBS)

    JMAP health behavioral specialists are trained, licensed and certified social workers who ensure that patients within JMAP have access to mental health services. That involves both coordinating care and providing a subset of those services (e.g., talk and behavioral-cognitive therapy, under the supervision of a psychiatrist).

  • Pharmacists

    JMAP population health pharmacists are clinically trained pharmacists who hold a doctorate of pharmacy. They can perform a variety of tasks for JMAP patients, including making sure patients are not taking unnecessary medications; helping physicians treat their patients with the most cost-effective medicines; reviewing prescriptions for potential drug-drug interactions; assisting physicians with dose titration protocols (so that patients can get necessary medication adjustments without requiring a full doctor's visit); educating patients about the drugs they take and how to take them; and assisting the JMAP quality team with documenting the quality of care in the JMAP population.

  • Specialist Access

    Appointment access teams help JMAP physicians coordinate urgent appointments with world-class Johns Hopkins specialists when patients have medically urgent needs. This results in care that is both more convenient and less costly for patients and for Medicare.

Value-Added Services

The following services are available for physician practices to ensure program requirements are met and practice performance is enhanced.

  • Quality and Practice Transformation

    JMAP’s Quality and Transformation team works with JHM and partner practices to provide guidance on program requirements. They also facilitate practice transformation through the development of processes to establish and maintain quality improvement projects that aim to optimize performance. Practice transformation is accomplished using data analytics, reviewing primary care office workflows and incorporating best practices to improve care. Throughout, the team strives to transform the culture of ambulatory care — providing practices with the data and tools to deliver high-quality, patient-centered care while advocating for for innovation and continuous performance improvement.

  • Legal and Regulatory Compliance

    JMAP's legal and compliance teams employ both internal and external teams of lawyers, tasked with making sure that all JMAP patient data is safe and that all JMAP physician practices and partners know what they need to do to comply with Medicare regulations. These services allow our independent physician practice partners to engage in value-based innovation without the administrative burdens and costs of going it alone.

  • Communications

    JMAP's communications and marketing team brings a professional touch to producing materials for patients, physicians and caregivers. Notable examples include JMAP's care coordination testimonials and this website. By pooling resources together, JMAP physicians help themselves and their patients to gain access to higher quality care than they could afford on their own.

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