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Dome - Eliminating Boundaries of Care

Dome February 2013

Eliminating Boundaries of Care

Date: February 1, 2013

Picture a scenario that is all too common: After several trips to the emergency room because of chest pain, dizziness and shortness of breath, “Mr. Jones” is admitted to the hospital for heart valve replacement surgery. In reviewing his history, the care team discovers that the 56-year-old patient often misses primary care appointments, lives alone and takes medication that requires frequent monitoring—all factors that make it difficult for Mr. Jones to manage his own care and increase his chance of being readmitted to the hospital after discharge.

Thanks to a new initiative in place at The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, however, Mr. Jones can now more easily receive the extra assistance his multidisciplinary care team recommends: home health services, vouchers to cover his medication co-pays and a transition guide to help coordinate his care when he returns home. Mr. Jones learns how to take care of his medical condition and, with the help of his primary care doctor, avoids readmission to the hospital.

This is the goal of the Johns Hopkins Community Health Partnership, a new health care delivery model launched last year with a $19.9 million, three-year “innovation grant” from the Centers for Medicare & Medicaid Services. The initiative, which builds on existing efforts, such as the work of the Johns Hopkins Health System Readmissions Task Force, seeks to address one of the nation’s largest health care challenges: how to improve the quality of care that individuals receive and the overall health of the community while preventing unnecessary and costly hospital readmissions and emergency room visits.

Solutions developed at Johns Hopkins, leaders say, may also guide medical institutions across the country as they confront similar challenges of health care reform.

This ambitious effort means transforming the way health care is delivered in the hospital, home and community, according to Constantine “Kostas” Lyketsos, director of psychiatry at Johns Hopkins Bayview and co-leader of the Community Health Partnership’s behavioral health program. He says the initiative will bring patients “smarter care at the right time and at the right place” by better connecting them with primary care physicians and improving coordination among the members of their health care team.

“We’re going to be much more patient-centered,” he says. “We’re going to spend a lot more time in the community and also think a lot more about transitions in and out of the hospital.”

Initially, the program will focus on helping frequent users of hospital care in East Baltimore and patients hospitalized on certain units at The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center. Plans call for nearly all adult inpatients at those hospitals, along with an estimated 3,000 community members deemed as high-risk for hospitalization, to reap the program’s benefits by July 2015.

Inside the hospital, those benefits include risk assessments and individualized care plans created by a health care team with members from pharmacy, physical therapy and case management, as well as nurses and physicians. Patients and their caregivers can learn how to manage their health conditions via computer tablet courses. After discharge, transition guides and community health workers will help support patients and pay home visits to those most at risk to be re-hospitalized.

A new provider and patient communication portal will improve coordination between inpatient and outpatient teams, including some based at skilled nursing facilities.

Another novel aspect of the program is placing case managers and behavioral specialists, such as counselors and social workers, in primary care practices and health clinics. “Many patients treated for a chronic illness, such as diabetes or heart disease, may also have a mental health condition or a problem with substance abuse that requires attention,” says Chris Durso, director of geriatrics and gerontology and another Community Health Partnership leader. On-site behavioral health specialists will save patients from having to set up separate appointments for help, he says.

“Supporting primary care doctors with new resources allows them to spend more time with patients and really understand not just their acute problems but the direction of their health in general,” points out Patty Brown, president of Johns Hopkins HealthCare and deputy project director for the Community Health Partnership.

The new model of patient-centered care also encourages individual health care providers to reach beyond their usual work spheres. “Maybe the patient doesn’t have permanent housing, or maybe he or she has a challenging social situation or a health need that’s going to require some additional planning,” says Community Health Partnership administrator Scott Berkowitz, who is also Johns Hopkins’ medical director of accountable care. “That’s where the team approach of working together to address those challenges is really going to make a difference.”

—Shannon Swiger


Redesigning Hospital Care Delivery

Multidisciplinary Care Planning

Providers used to work independently, but now the entire care team will discuss and plan each patient’s care together each day during multidisciplinary rounds. Each participant—whether pharmacist, physical therapist, social worker, nurse or doctor—will contribute to a holistic view of the patient’s health.

Risk Screening

Patients will undergo risk screening to assess what health care services they may need after leaving the hospital. Those with a higher level of need, and who may be at a greater risk for readmission, will be evaluated further. By assessing factors such as how well patients understand their condition, if they use high-risk medications—like insulin and blood thinners—and their history of hospitalizations, the health care team can anticipate and address problems that could return patients to the hospital.

Patient Education

Providers will identify what patients and their caretakers need to know about their condition earlier and will discuss these issues with them more frequently. A patient with congestive heart failure, for example, may receive up to 12 hours of training before leaving the hospital.

On some units, patients and family members can complete computer tablet-based modules to learn about their specific health conditions and how to care for them.

Seamless Care Transitions

Transition Guides

Transition guides are trained nurses who first meet patients with a high risk for readmission while they’re still in the hospital. After discharge, guides may call patients or arrange home visits to check their medications and assess whether they understand how to use them. Additionally, they may look for other potential barriers to recovery. Transition guides reinforce the discharge plan and can help coordinate follow-up appointments with primary care providers.

Post-Discharge Care Plans

Patients’ teams will work with them to develop care plans that outline goals and next steps. Primary care physicians will also receive a copy of that plan after their patients are discharged.

Improving the Handoff

A Johns Hopkins-developed system allows inpatient doctors to now inform primary care physicians electronically about their patients’ admissions and discharge plans. Electronic medical record systems like Epic will further enhance communications between providers and their patients.

Community Care Teams

Placing Behavioral Health Specialists in Primary Care Clinics

On-site behavioral health specialists will help patients lose weight, stop smoking and follow their medication regimen, as well as counsel and screen them for substance abuse or conditions such as anxiety. New on-site case managers will complete assessments, coordinate care with primary care doctors and others and arrange follow-up appointments. 

Community Health Workers

Community health workers in patients’ own neighborhoods will connect them with local resources, such as where to find healthy foods or support services, and help them overcome barriers to accessing needed care.

Related Content

To learn more about the Johns Hopkins Community Health Partnership: