Care Coordination Model

The JHM care coordination model provides a comprehensive and patient-centered approach to improving care for our Medicare Fee-for-Service beneficiaries in the primary care setting. The care coordination model was developed with the following guiding principles in mind:

  • Deliver evidence-based care coordination interventions

  • Deliver care via a patient-centered and flexible care model in the least resource- intensive setting

  • Support seamless integration of care across the care continuum

  • Maximize primary care practice presence of care team members

  • Create a framework for structured coordination between providers and care team members

  • Ensure accountability of outcomes among all care team members

Our Care Team

JMAP’s goal is to provide health care that is custom-built for each patient. Within our care coordination model, we provide access to the following care team members for patients, based on their individual needs, with the goal of achieving higher quality and higher value health care for our Medicare Fee-for-Service beneficiaries.

CFCT Roster (JHED ID-protected)

Value-Added Services

The following services are available for physician practices to ensure program requirements are met and practice performance is enhanced.