What if a health system assigned a whole team of health care professionals to monitor the well-being of one patient?  

It sounds inefficient and expensive.

But a four-year Johns Hopkins study designed to improve health outcomes for thousands of East Baltimore residents found that, if done properly, the opposite is true.

Not only did care teams help East Baltimore and eastern Baltimore County residents get healthier, but the teams also contributed to significant savings of Medicare and Medicaid dollars.

The Johns Hopkins Community Health Partnership, or J-CHiP, a pilot program funded in 2013 by a $20 million Health Care Innovation Award from the federal Centers for Medicare & Medicaid Services, aimed to reduce barriers to care for low-income East Baltimore residents, as well as reduce hospital readmissions for many adult patients with acute health problems at The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center.

The study’s authors — a team of physicians, researchers, nurses, administrators and health policy experts from The Johns Hopkins University, the Johns Hopkins Health System and community partners — published their results this fall in the Journal of the American Medical Association (JAMA) Network Open.

Scott Berkowitz, M.D., M.B.A., cardiologist and senior medical director of accountable care for the Office of Johns Hopkins Physicians, was the lead author of the JAMA article. He reported a Medicare and Medicaid savings of $113 million based on an independent program analysis performed by NORC, a nonpartisan research organization based at the University of Chicago.

“We set out to assemble a care-coordination model that could help keep people healthy and out of the hospital and to keep those already hospitalized from being readmitted,” says Berkowitz. “We believed we could also do it efficiently enough to improve care and at the same time save payers money. Our study suggests that this model of care coordination was associated with improved health outcomes and substantial cost reductions in an urban, academic health system.”

J-CHiP studied thousands of adult patients covered by Medicare or Medicaid who were hospitalized at The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center between 2012 and 2015. The goal was to make sure that patients who were going home from the hospital received a coordinated plan to keep them from returning for the same problem. Post-discharge phone calls from nurses, patient education materials and visits from J-CHiP staffers provided patients and their families or caregivers with encouragement and instructions for follow-up care.

Berkowitz says J-CHiP’s inpatient care-coordination plan contributed to a savings of $29.2 million for Medicare and nearly $60 million for Medicaid. The Medicaid group saw a dramatic decrease in emergency department visits that occurred 90 days after hospitalization, reducing that number by 133 per 1,000 patients, or nearly 1,900 emergency visits.

Preventing health crises in East Baltimore

In addition to the inpatient plan, another of J-CHiP’s goals was to better coordinate care for people in East Baltimore and eastern Baltimore County who were identified as high-risk for hospitalization because of living in urban poverty.

“Patients from these areas frequently suffer from mental health and substance abuse conditions,” says study co-author Constantine Lyketsos, M.D., M.H.S., professor and chair of psychiatry at Johns Hopkins Bayview Medical Center. “We worked to establish an integrated behavioral health model in the interest of improving care for these patients.”

The J-CHiP program included a partnership among Johns Hopkins and two East Baltimore human-service nonprofit organizations: Sisters Together and Reaching (STAR) and the Men and Families Center. The nonprofits were vital to the project, supplying additional staff and expertise to provide outreach and support for neighborhood residents at high risk for hospitalization.

For the 2,500 Medicaid patients in this group, there was a $24 million savings for the government payer. The study’s authors associate care coordination with a reduction of 200 emergency department visits, almost 70 hospitalizations, and nearly 80 readmissions within 30 days of original hospitalization.

An important element of J-CHiP was the formation and hiring of care teams to reduce treatment barriers for underserved East Baltimoreans. Multidisciplinary teams assigned to high-risk Medicare and Medicaid beneficiaries included physicians, care managers, health behavioral specialists and community health workers. Also key to success was engagement and collaboration with community-based organizations.

“More efficient and less expensive care were among the many encouraging results that came from the J-CHiP study,” says Patricia Brown, senior vice president of managed care and population health for Johns Hopkins Medicine. “We’ve already incorporated many aspects of the pilot program into the work we deliver with our community partners.”