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Dome - A Health Care Delivery Model That Delivers

Dome December 2014

A Health Care Delivery Model That Delivers

Date: December 5, 2014

The Johns Hopkins Community Health Partnership is working to cut down readmissions and improve health in East Baltimore.


Multidisciplinary inpatient rounds at The Johns Hopkins Hospital are a part of the care coordination that improves outcomes and reduces risk of readmissions.
Multidisciplinary inpatient rounds at The Johns Hopkins Hospital are a part of the care coordination that improves outcomes and reduces risk of readmissions.

The patient had diabetes, with cellulitis and poor blood sugar control, despite regular doctor visits and insulin prescriptions. Why her blood sugar levels remained stubbornly high was a mystery, says Michael Fingerhood, an internist and addictions medicine specialist who works closely with the Johns Hopkins Community Health Partnership (J-CHiP). It took the combined insights of her J-CHiP care team, which included a community health worker, pharmacist, home care nurse and Fingerhood, to determine the source of the patient’s problem. And it took their combined efforts to fix it. 

“She couldn’t see well enough to draw up the insulin dose and was embarrassed to admit this,” Fingerhood says. “When we put the pieces together, she was prescribed insulin pens and encouraged to see an eye specialist.” With the team’s help, she followed through. Three months later, her blood sugar levels had improved significantly.

Team-based care with an emphasis on care coordination is a hallmark of J-CHiP, the health care delivery model launched in 2012 with a $19.9 million, three-year “innovation award” from the Centers for Medicare & Medicaid Services. Built on existing efforts, such as the work of the Johns Hopkins Health System Readmissions Task Force, the initiative addresses one of the nation’s largest health care challenges: how to improve the quality of care for individual patients and the overall health of the community while preventing unnecessary and costly hospital readmissions and emergency room visits.

J-CHiP patients are adults of all ages and include a high-risk cohort consisting of patients covered by Medicare and by Priority Partners, the Medicaid managed care organization owned by Johns Hopkins HealthCare and the Maryland Community Health System. They live primarily in East Baltimore. The program works with entities outside of Johns Hopkins, including skilled nursing facilities and community-based organizations, such as the Men and Families Center and Sisters Together And Reaching.

Scott Berkowitz, the program administrator, says that J-CHiP is preparing Johns Hopkins Medicine for the future of medical care. A recent story in USA Today about a patient who benefited from the program shows how this Johns Hopkins model of coordinated care seeks to cut down hospital readmissions for “super-utilizers,” the 1 percent of the population who account for 22 percent of health care spending.

–Christina DuVernay

As seen in the 2016 Biennial Report. Learn more.

J-CHiP BY THE NUMBERS

2,800: Patients who have been assigned a community health care worker to help coordinate their care

95: New health care workers hired and trained to work with the program

34: Inpatient units where participants have received care at Johns Hopkins Bayview Medical Center and The Johns Hopkins Hospital

8: Participating medical practice sites in the East Baltimore community

5: Partnerships with skilled nursing facilities in the East Baltimore community

59,048: Total number of people who have been offered services associated with J-CHiP

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Watch a video and learn more about J-CHiP: bit.ly/JCHiP2video