Johns Hopkins HealthCare is always looking to improve members’ health. No matter where they are on their health journey, we have programs designed to help them get where they want to go. We encourage our members to start small. SMALL STEPS, BIG CHANGE, our approach to member health, helps our members get closer to their best self, with the support they need, when they need it.
Our care management model promotes prevention skills, performs health risk identification, and manages member compliance to avoid costly treatments. We not only outreach to the sickest members to stabilize and manage conditions, we guide healthy members further along the prevention path. We are here to support all members wherever they are on the health continuum.
To refer a patient for Care Management services, call 800-557-6916, Monday through Friday, 8 a.m. to 5 p.m. You can also email [email protected].
For members living with a mental health condition such as depression, autism spectrum disorder, anxiety or addiction, we provide care management services, which may include access to confidential care coordination support.
These clinicians use a unique team approach to assist members through their treatment needs. Services include coordination with all providers and treatment resources.
Behavioral health services can be obtained by calling 800-557-6919, Monday – Friday, 8 a.m. – 5 p.m.
Complex care management provides care management services for members with one or more complex medical conditions and over or under utilization of health care services. JHHC recognizes that individuals often have two or more health problems that can be well served by evidenced-based care management.
We provide service to adults with asthma, diabetes, cardiovascular conditions, chronic obstructive pulmonary disease, sickle cell, cancer, pain management, Alzheimer's, rehabilitative needs, HIV/AIDS, seizure disorders, developmental disabilities, chronic kidney disease and chronic lung disease. We provide services to children 18 years and younger with chronic conditions such as asthma, diabetes, sickle cell disease, neurological devastation, various genetic syndromes, cancer and morbid obesity, or after an organ transplant.
- Complex Care Management Assessment completed on all members
- Coordinate transitions of care that do not fit within the Transitional Care Services model
- Coordinate care with PCPs, specialists, DME/service providers
- Support self-management
- Address barriers and gaps in care by creating innovative solutions and involving community resources
- Education on signs and symptoms of worsening disease
- Identify appropriate level of care
JHHC’s Health Educators are a wonderful resource for all of our members and providers. Our educators advocate, encourage and teach about healthy lifestyles and living well with a chronic condition. We also serve our special needs population. Services can be delivered through the following educational methods:
- Health education classes and activities: view our program descriptions and current class dates, times and locations at the member’s health plan website under Health and Wellness > Health Education.
- Development and distribution of health-related newsletters, fact sheets, and brochures
- Collaboration with case managers in providing member education to reinforce member’s treatment plans
Health Educators can be reached by calling 1-800-957-9760 or email to [email protected]
Maternal Child Health
Maternal Child Health (MCH) care management is available to prenatal and postpartum members, families with newborns and children. With every successful outreach, we offer health education, community resources, care coordination and promote access to quality health services. We strive to contact and engage with members as soon as possible. With family engagement in goal setting, we improve self-reliance and build confidence in navigating the health care system.
- Pregnancy Support- OB nurse care managers provide pregnancy support to high-risk pregnant members with a history of current symptoms of asthma, diabetes, pre-term labor, substance abuse, hypertension and or adolescent pregnancy. Social determinants of health are assessed so that barriers influencing a member’s engagement in prenatal or postpartum health are managed. Care managers coordinate the member’s care with OB providers, maternal-fetal medicine and/or other specialists during pregnancy. We encourage member participation in prenatal care, medication management, healthy eating, safe home environment, stress reduction, self-care and improved emotional health. Members remain in care management after delivery expanding the opportunity for member care in the postpartum period.
- Support for NICU graduates and children - Pediatric nurse care managers engage with members 18 years and younger with risk factors that include, but are not limited to, conditions such as asthma, diabetes, sickle cell disease, behavioral and neurological disorders, genetic syndromes, and NICU graduates. A comprehensive assessment assists the care manager in identifying needs, barriers and social determinants of health that assist the care manager in understanding the health and wellness of the newborn or child. The care manger actively interfaces with multiple providers, home health care, community agencies and the school system, when applicable, to aid in meeting specific physical, psychosocial and emotional needs of the developing child and family across the health care continuum.
Services are provided to members showing a potential risk, an anticipated risk, or a known risk, with the intent to prevent that risk from becoming a significant care need. Support includes health and wellness promotion such as exercise, nutrition and screenings, but these services are also designed to stabilize a member’s health to prevent it from worsening. Qualified health care professionals will provide assistance to help close gaps in care, which may include: annual wellness visits, screenings, monitoring labs to ensure therapeutic levels of a medication, earlier intervention, and engagement with a health care provider to proactively manage a potential health exacerbation based on clinical indicators (i.e. elevated blood pressure and HbA1c that are not within range). Services include:
- Health maintenance and prevention reminders to promote self-management skills
- Health Education
- Recommendations on how to manage and maintain overall health and wellness
Transition of Care
Provided following a health event, such as a recent hospitalization, the diagnosis of an illness, a life-changing event such as a birth, or a decision to receive long-term care services). Designed to assist members and their loved ones with coordinating a set of clinical resources and navigating the complexities of the health care system.
- Coordination of durable medical equipment and supplies
- Medication management and reconciliation
- Appointments with providers (existing and newly identified)
- Understanding diagnosis
- Establish a relationship with providers
JHHC's health programs and services are voluntary and are provided at no cost to the member. Members identified with certain needs may be automatically enrolled but are under no obligation to participate.