Table of Contents
FY25 By the Numbers
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50+
Clinical Spaces
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1.1 million
Patient Encounters
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700+
Physicians & Advanced Practice Providers
Support and Education Programs Improve Hiring, Retention of Advanced Practice Providers
With programs that deliver one-on-one mentoring and specialized clinical education, Johns Hopkins Community Physicians (JHCP) has increased hiring and decreased turnover of its advanced practice providers, says Elisabeth Stephens, director of advanced practice providers for JHCP.
Stephens is the first to hold the job of APP director, created in 2022 to support these providers at a time of high burnout and turnover.
Her first major initiative was to create the Transition to Practice (TTP) program, a yearlong initiative that pairs recent graduates who are entering the JHCP workforce with seasoned APPs who help with the real-world decision-making and responsibilities of the job.
New in the past year is the implementation of continuing education sessions through utilization of Physician Education and Assessment Center (PEAC) learning modules, which offer deeper dives into specific areas of clinical knowledge, says Stephens.
Stephens tapped experts in the JHCP Academy of Clinical Excellence, who developed eight one-hour learning sessions in specialties including neurology, endocrinology, orthopaedics and hematology. Topics include migraines, diabetes and weight management, chronic back pain and anemia.
The sessions, live Zoom meetings that were recorded for future use, were not mandatory, but most new APPs participated, bringing their questions and observations to the discussions.
All clinicians in JHCP have access to the modules. “There's a pre-test and a post-test, so it helps us also measure learning and progress,” Stephens notes.
The programs are empowering this group of new graduates with advanced clinical knowledge, connections to each other, and connections to colleagues who are experts in their field, she says.
Since the inception of TPP, 12 recent-graduate APPs were hired and just two have left, both for family reasons, she says. JHCP currently has 84 APPs on staff, she says, up from 64 when she started in the role.
“The support JHCP has shown in the development of a TTP program for advanced practice clinicians shows the significant commitment the organization has made to the growth of our advanced practice workforce,” she says.
Expanded Access for USFHP and VirtualCare
To increase access to primary care, Johns Hopkins Community Physicians (JHCP) leadership undertook initiatives to help military families in the US Family Health Plan (USFHP) establish care and extend hours for Johns Hopkins Medicine Primary VirtualCare, which provides virtual urgent care within 24–48 hours.
Some people with USFHP, which serves active duty and retired members of the military and their families, were having trouble making their first appointment with JHCP within the 30-day window required to establish care.
“Especially among the active-duty family population, because people are always moving, there’s a higher turnover of those patients,” says Kevin Groszkowski, medical director for the JHCP USFHP program and an internal medicine physician at JHCP’s Annapolis/Edgewater location. “A lot of sites had limited access for those patients.”
Groszkowski, a captain in the Navy Reserve who has served as a flight surgeon and medical officer for multiple Navy and Marine Corps commands, worked with JHCP leadership, including Melissa Blakeman, medical director of patient access, to remedy the problem.
The team looked at historical demand and turnover of patients with USFHP insurance at different JHCP sites, then set aside proportional blocks of time to make sure new patient appointments were available. Additionally, a new visit type for USFHP members was added to scheduling software. The changes make it easier for new patients with USFHP to schedule first visits within the 30-day requirement, and also brought the new patient median lead time down from about 25 days to less than 15.
In spring 2025, JHCP established consistent evening and weekend hours for Primary VirtualCare, which launched during the COVID-19 pandemic. Adjusting schedules in FY25 has allowed VirtualCare to now be open from 8 a.m. to 5 p.m. on weekends and until at least 9 p.m. on weeknights. Previously, the service was available until about 7 p.m. on weekdays and sometimes on weekends.
“That has allowed us to be there when patients need us more,” Blakeman says. “We’re still learning about the demand, but more patients are getting timely and convenient care with the new hours.”
Building a Better Pediatric Experience, for Clinicians and for Patients
Michael Crocetti’s skills as an Epic builder have been put to good use in FY25. Together with his team of pediatricians, he improved the medical records experience for clinicians and added important screening questions for patients.
For clinicians, they added an option to use artificial intelligence to record patient visits and draft clinical notes. They also trimmed “note bloat” so that providers see only the most relevant information, with the rest accessible by hyperlinks.
“We took the note and we shrank it, so it’s easy for the clinician to pull up the data they need, order what they need and document what they need, all in one view,” says Crocetti, Johns Hopkins Community Physician's (JHCP) chief of pediatrics.
New screening tools now pop up to improve patient care. One is a follow-up to an existing mental health screening, which adds questions about suicidal ideation if a patient says they’ve recently considered self-harm, helping the clinician assess risk and implement a safety plan.
Another new screening, part of the exams that teenagers need before playing on school sports teams, evaluates cardiac risk by asking about family history and symptoms such as fainting or chest pain while exercising.
Tools within Epic help pediatricians meet metrics for visits, screenings and vaccinations. In FY25, pediatrics exceeded its quality and patient experience targets in five of six metrics (adolescent well visits, chlamydia screenings, lead screenings, adolescent combination vaccines and depression screenings), and improved in three of six (chlamydia screenings, combination vaccines for adolescents and depression screenings).
Looking ahead, the pediatrics team is developing signs that will guide parents in how to hold their baby during an exam in order to prevent falls from exam tables; and a new tool in the electronic medical system to guide clinicians in next steps if a minor arrives for an appointment without a parent.
Quality Improvement Scores Climb in 2024
Johns Hopkins Community Physicians (JHCP) reached its target scores on eight out of nine health care quality metrics as measured by the Healthcare Effectiveness Data and Information Set (HEDIS), a standardized set of measures used to evaluate and compare medical practices’ performances as well as health plan performance and quality. In calendar year 2024, the eight metrics were in the 90th percentile of HEDIS scores, and the ninth was within 3% of its target.
The number of metrics reaching their targets increased from five in 2023.
The scores indicate percentages of patients who have engaged in certain kinds of preventative care and disease management. The eight measures meeting targets included adolescent immunizations, breast cancer screening, colorectal cancer screening, controlling high blood pressure, depression screening and follow-up, diabetic HbA1c testing and levels, well visits for those aged 12–21, and well visits for those 65+. Statin therapy in diabetes patients without cardiovascular disease reached 86.8%, just shy of its target of 89%.
HEDIS is administered by the National Committee for Quality Assurance.
Jennifer Bailey, JHCP’s vice president of quality and transformation, says various efforts have raised the scores, including a “metric of the month” focus across JHCP, in which each practice utilizes tools such as Epic clinical decision support; patient outreach through MyChart and postal mail; and direct access scheduling, which allows patients to schedule certain screenings without needing a referral from their primary care provider.
“It’s a team effort to improve quality,” Bailey says. “It encompasses every role.”
These efforts are also driven by the Performance Improvement (PI) Committee, which meets monthly and includes senior JHCP leaders and representatives from various specialties, as well as patient representative Sandra Boyd. A proactive member of the committee, Boyd recalls a recent recommendation she gave to make a letter to patients about scheduling a screening more personal and less boilerplate.
“It’s great to see those HEDIS numbers improve,” Boyd says. “When those numbers improve, patient care improves.”
