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Sharing Our Journey: J-CHiP Success Stories

Below are stories submitted by staff members on the care teams about the impact that the Johns Hopkins Community Health Partnership has on our patients/members, their family members and caregivers, as well as our own employees, care teams and the culture of the program. These examples reflect the commitment of our team to help our members stay healthy and encourage self-management of their health conditions.

Barriers to Care

"A year and a half ago, a member approached me asking for housing assistance. She was homeless and was not taking good care of herself. Together, we completed a housing application, and within nine months, she moved into her own one-bedroom apartment. Not only was she happier, but she was healthier! She has since called her whole J-CHiP team on multiple occasions and expressed her deep gratitude for our help!"

"I am a community health worker and assisted two J-CHiP members, a married couple who was in need of transportation. I assisted them with the MTA Mobility application, which included applying and accompanying the wife to the MTA Mobility interview because she is legally blind and requested a community health worker’s presence at the interview. The husband went for an interview after his wife, and now both members utilize MTA Mobility and Taxi Access. Both members were pleased and very appreciative for my assistance and are very glad the J-CHiP program exists."

"As a case manager, I reached out to a patient and made a joint home visit with another member of the J-CHiP care team. One of the barriers to care identified was difficulty affording medications, as she and her husband usually have to choose between food, energy bills and medications. The patient was out of several medications and was taking half-doses of essential medications, including those prescribed for diabetes. We assisted the patient with completing a pharmacy assistance application and also applied for energy assistance. Within several weeks, the patient was approved for a year’s supply of free medications. The patient has since received assistance with her energy and water bills and also occasional food baskets from the J-CHiP food drive. On a recent clinic visit, the patient verbalized gratitude to the team and stated “we made her day.”

"The family of an elderly J-CHiP member with mild dementia came to us seeking help for the member remembering basic toileting/diaper changes. After conducting a home visit to determine the patient’s barriers to self-care, in addition to providing patient education on risk and prevention of skin breakdown, we developed a poster to visually help the patient remember what self-care things he needed to complete at different times of the day. Since then, his self-care and overall health has improved."


Patient Engagement: Staying Out of the Hospital

"One of our patients was hospitalized several times within a month. Pretty much every week, he had one to two hospitalizations. After his last hospitalization, this patient was transferred to a nursing home for rehabilitation. He was in the nursing home for approximately four weeks, and every week, the patient’s case manager and I would visit him and check on his progress. While he was in the nursing home, we also coordinated his care for after his stay, figuring out what we could do to help prevent any more hospitalizations. The case manager and I enrolled the patient in a day program, which he would attend three days a week. Since the patient has been out of the nursing home, he has been attending the day program and has not had one hospitalization. The patient is also a team assistant at the day program and leads their arts and crafts sessions. He attends his primary care provider visits regularly and is performing well in daily life. This patient has now been going to the day program for over a year and has progressed greatly. The entire team is excited for his success."

"We had an encounter in which a patient in her 80s was brought to the clinic for her first appointment here by her daughter. The daughter had decided that she could no longer provide care for her mother after a recent argument and was seeking assistance. The mother was recently discharged from The Johns Hopkins Hospital about two weeks prior and was discharged to her daughter’s care after a long separation. Through the utilization of teamwork and a great deal of care coordination, we were able to obtain an emergency placement in an assisted living facility and prevented the need for a social admission to the hospital. We are continuing to coordinate care with the family, the patient and her care providers to stabilize her health and social situations with a care plan developed with the patient’s goals in mind."


Patient Engagement: Re-Engaging Patients in Their Care

"Being able to help patients achieve their health care goals is very rewarding. When I initially started at my practice as a case manager, I had a patient who was not engaged. She was on Coumadin for having a history of multiple DVTs but had not been in to see her primary care provider in a while. It was important to me that we follow up with her because if left untreated, this could be dangerous. The community health worker and I went and saw the patient at home and made her an appointment to be seen at the clinic and at anticoagulation. She made both appointments and has been engaged ever since. Sometimes when a patient sees that someone else cares about them and their health, they begin to care also!"

"A J-CHiP member was frequently missing appointments with her primary care physician. She was often disgruntled at clinic and not engaged in self-management goals with the care management team. She had difficulty establishing trust even after several outreach interventions. The team discussed the case during multidisciplinary rounds and agreed to close the case. A last effort was made by the team at the clinic, with the patient requesting to have her case remain open and agreeing to meet with the care management team at her home. The member fully engaged in the home visit with an increased level of comfort noted by the team. She was very open throughout the assessment, allowing her to develop a better rapport and establish trust with the team. The team learned of a hearing barrier, which may have led to frustration at the clinic. She is now receiving multiple services from resources in the community and has developed several goals with care management. Through the outreach, the member’s husband has also been referred to care management services so as to fully assist the family. She provided hugs to the team and requested continued home visits for follow-up."

"A patient who was not seen in primary care for more than a year was able to re-engage in not only primary care but specialty care, including psychiatry for the first time in many years. This was due to our J-CHiP team’s constant outreach and addressing his transportation needs."

"My journey as a Community Health Worker is amazing. I have learn how to assist members in becoming self-sufficient with their healthcare. They are able to make and keep appointments, have effective transportation, and the ability to overcome social barriers as they arrive. Members actually look forward to my pleasant face and smile when they have clinic appointments. I was able to create a food drive for CHW's to assist those members in need of urgent food needs. I love what I do."

“I am not unlike the patients I work with every day. I have faced many of the obstacles my patients are working to overcome. Although I have been clean for 15 years, my struggle with addiction sent me down a dark path. Having pulled myself out of the darkness with help from others, I relate well to some of my patients with similar struggles. I wreaked havoc in East Baltimore. I caused a lot of chaos in these neighborhoods. I view my role as a J-CHiP community health worker as an opportunity to help East Baltimore residents move from 'havoc to healing.' Each patient interaction is a way to give back to the city I have always called home. My self-proclaimed virtues are honesty, open-mindedness, and a willingness to serve others. I strive to meet my patients where they are, both physically and emotionally. From sitting in waiting rooms to comforting patients prior to surgery, to getting on their level to encourage healthy eating and exercise, I engage my patients by relating to their struggles. J-CHiP’s successes are borne from the strong relationships patients have with their care team. We at J-CHiP are honored to provide our patients and staff the opportunity to share, learn, and give back by empowering each other to lead healthy lives.”


Patient Engagement: Substance Abuse Recovery

"As a health behavior specialist, a case manager referred a patient to me who has a long history of alcohol abuse. I met with the patient while in the hospital and discovered he was discharged a few days before for the same reason. After discussing the patient history, motivation and barriers, the patient stated he would be interested in going to treatment. The patient and I called the treatment facility together and set him up for an intake appointment in two days. I provided education on substance abuse and recovery, and encouraged the patient to use his support system to manage his cravings."

"I collaborated with a young woman on an inpatient medical unit who was in active withdrawal from opioids. Together with her external substance use disorder treatment provider, the attending physician on her unit and the psychiatric services team, we developed a plan that was agreeable for all parties. An order for Suboxone was initiated and was also prescribed upon discharge to last through the weekend until she could be placed in a partial hospital program for more intensive services. The patient subsequently completed her stay in the partial hospital program, and returned to a transitional house and her substance abuse disorder treatment provider successfully."

"One of my patients had been using alcohol for decades. Her compliance with medical appointments and recommendations was poor. She presented in emergency rooms frequently for gastrointestinal problems that included rectal bleeding. The patient was underweight due to a poor diet and would frequently feel faint or fall as a result of low blood pressure. I worked at engaging this patient for over 10 months to help prepare her to recognize that her drinking was a problem directly impacting her health in a negative way. I visited with the patient during a hospitalization for gastrointestinal bleeding and convinced her to attend a rehabilitation program. The patient completed a three-week, intensive inpatient program. She has now been sober for 15 months, attends Alcoholics Anonymous and has a sponsor. We have worked together since she was released from rehab to provide support to ensure that she continues to maintain her sobriety. Her gastrointestinal issues are resolved, and she hasn’t had any emergency room visits in over a year."

"A patient was referred to me by her primary care doctor for help with smoking cessation. When I initially spoke with the patient, she was interested in cutting down on smoking but was reluctant to come in to meet with me. She had a lot of other appointments to keep track of, and her asthma sometimes made it hard to get out of the house. Also, she had been a smoker for more than 40 years, and she wasn’t sure she would be able to quit. We agreed to do the smoking cessation sessions over the phone. I sent her the information in the mail, and then we talked on the phone every week. She seemed to enjoy the conversation, and she made several attempts to quit. But she always started smoking again very quickly. I think both of us got a little discouraged. But I tried hard to use patient engagement strategies to increase her motivation to quit and her confidence that she was capable of being successful. I reminded the patient that each time she quit — even for a day — she learned more about what did and didn't work for her. I continued to try to evoke her reasons for wanting to quit in the first place and reminded her of those reason when she got discouraged. Then, she was hospitalized for breathing difficulties. She was unable to smoke while in the hospital and decided to use that as an opportunity to quit for good. That was seven months ago, and she has not started smoking again. She has asked that I continue to call her to check in, and we still talk every week. Sometimes, we just talk for a few minutes, and she proudly reports how long it has been since she quit. Other times, we talk about her continued health problems or the joys and challenges of spending time with her grandchildren. Because of the relationship that we have built, she has begun to talk a little about physical activity and to think about how she could be more active."

"As a nurse case manager, I get the opportunity to engage with patients and assist with barriers to health care. A community health worker and I have had several conversations with a patient with a history of drinking alcohol regarding quitting drinking and the importance of better nutrition, as she will go days without eating. The patient has finally decided she would like to get help. I called daily to a couple of detox inpatient clinics for about two weeks straight. Finally, Johns Hopkins Bayview Medical Center had a bed available, and the community health worker and I went to the patient’s home that day to assist her with completing the assessment via phone. During the phone call, the patient was asked to bring ID, which we learned she didn’t have; however, the patient took the initiative to get her ID and Social Security card. As soon as the patient gets her ID, the community health worker and I will assist with getting her into detox, as she is still ready. Since being engaged with this patient, she has become more compliant with showing up to appointments, and she contacts the community health worker almost daily regarding detox."


Culture Change

"Today, I saw the power of J-CHiP unfold. It is all too often that this great work and service to our members seems to become mundane, but I would like to highlight a brief narrative on teamwork, member safety and intervention. A member was enrolled in J-CHiP through the original screening process and was contacted by our nurse care manager and community health workers. She has been engaged in J-CHiP services for almost two years now and in times of crisis has sought out clinical intervention from the health behavior specialist team. She has formed an ongoing working relationship with our community health worker and a trusting therapeutic relationship with her health behavior specialist. Recently this patient, already diagnosed with depression, began to experience severe distress.  She called her community health worker (CHW), stated that she “couldn’t do it anymore,” and asked for help and support. Her CHW headed straight to her house at 7:30 a.m., just after the telephone call. Her CHW sat with her, listened to her and offered her services. When the patient said she had thought about hurting herself, her CHW called the health behavior specialist (HBS). The HBS was able to speak to the patient and engage her in a safety assessment over the phone. It was apparent from the assessment that this patient needed a higher level of care, so while the CHW sat with the patient and assisted her in making plans for her children, the HBS was able to arrange further evaluation and inpatient therapeutic services to keep the patient and her family safe. The HBS was able to walk the patient through the process and answer her care questions. The HBS was able to coordinate and update the primary care physician throughout the process and team with the nurse care manger to manage all other medical care services. The patient was evaluated and admitted and is receiving the care she needs without multiple emergency room visits or long waits. It truly was the meticulous and timely teamwork of the J-CHiP team that was able to step outside the traditional realm of patient care to meet the needs of our patient. And really, that’s what we do every day."

 

This project is supported by Grant Number 1C1CMS331053-01-00 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The content of this web page is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.