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After Care Clinic (ACC)

The After Care Clinic has won the 2016 Office of Johns Hopkins Physicians' Innovations in Clinical Care Award.

2016 Innovations in Clinical Care Award - Rosalyn Stewart, M.D. and the Johns Hopkins After Care Clinic team

Rosalyn Stewart, M.D. and the Johns Hopkins After Care Clinic team are the 2016 recipients of the Innovations in Clinical Care Award at The Johns Hopkins Hospital. This team has had a marked impact on the rate of acute care utilization among adults who struggle to manage their health, leading to better outcomes and savings for the health system.

Mission Statement

The Johns Hopkins After Care Clinic (ACC) is designed to provide a safety net for patients discharged from the Johns Hopkins Hospital or Emergency Department who need rapid follow-up but cannot secure appointments within the necessary timeframe.  The goal of the ACC is to serve as a bridge for these patients – offering a setting where they can be assessed, treated, and transitioned back to a community provider for ongoing care.  The Clinic is intended to support at-risk patients and prevent unnecessary readmissions and ED visits for issues that could be handled on an outpatient basis.  It is not an urgent care center and not a primary care site. 

  • The Johns Hopkins After Care Clinic serves as a key resource for patients who have recently been treated in the emergency department or inpatient setting and are in need of short term follow-up and support as a bridge to appropriate longitudinal care.
  • The Johns Hopkins After Care Clinic promotes the safe and efficient transition of patient care from the acute care setting to ambulatory care by providing interim focused short term evaluations and provide key resources to help patients thrive in the outpatient setting. 

Services

  • Medical assessment, evaluation and treatment provided by physicians and advanced practice providers (NPs and PAs)
  • On-site phlebotomy services for blood work/lab tests
  • On-site pharmacy support for medications to be administered in Clinic and for take home prescription fulfillment
  • Nurses and pharmacists to provide education on conditions and medications as well as counseling on the use of medical equipment, wound care, or other self-care activities
  • Social workers and case managers to help coordinate services and provide guidance
  • Access to home care, transition guides, and other post-acute home-based services
  • Care coordination for on going medical care
Resources for Patients and Providers at the Johns Hopkins Hospital
Heart & Vascular InstituteComprehensive Diabetes Center
Comprehensive Diabetes CenterThe Access Partnership (TAP) (Español/English)
Financial Assistance Plans (Español/English)Federally Qualified Health Centers (FQHCs)
Maryland Health Connection/Apply for InsuranceWhat is a Managed Care Organization (MCO)?

Hours and Locations

The Johns Hopkins Outpatient Center
7th Floor (Department of Medicine)
Monday 4-8PM
Wednesday 1-8PM
Thursday 4-8PM
Friday 8-5PM
 

Eligible Patients

The After Care Clinic will accept adults discharged from adult inpatient units and from the adult ED who cannot get timely appointments (within 7 days) in their established primary/specialty clinic or who have no medical “home.”  Priority will be given to those at high risk for return, including patients with new chronic conditions (e.g. diabetes, congestive heart failure, high blood pressure) as well as those needing checks on wounds or devices.  Patients will be accepted regardless of insurance coverage or ability to pay.
Note:
  • If patients have PCPs, every effort is made to get them appointed in “home” office first, with Follow-Up Clinic being safety net if timely slot is not available
  • The ED should schedule in the ED follow up appointments in the Medical Clinic and in Surgery Clinic first prior to scheduling in JAAC.

Referral Process

Before scheduling an appointment within the ACC, every effort should be made to re-connect patients in the appropriate primary or specialty clinic (inside or outside Hopkins) following the established protocols of the referring department.  If an appointment cannot be secured in this fashion, then patients can be booked in the After Care Clinic as follows:

  • Go to Internal Medicine Clinic 762* within EPIC
  • Look for ACC Provider 1, Schedule patient within  the ACC provider slots for the date desired
  • Write the appointment information at the bottom of the After Care Clinic patient information sheet or card and ensure that it is given to the patient along with his/her hospital or ED discharge instructions

Contact Information

After Care Clinic: 410-955-0545
Appointments:  443-997-6222
 
Dr. Rosalyn Stewart/ Director, After Care Clinic
410-955-3613 (office)

Dr. Arjun Chanmugam/Co-Director, After Care Clinic
410-735-6461 (office)
achanmu1@jhmi.edu

Melissa Richardson/Director, Clinical Resource Management
410-955-9304