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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)

  • JMAP care managers provide a variety of patient-centered services. Our care management team has years of experience and includes nurses and licensed certified and clinical social workers. Among the services they provided are:

    • Medication Management – educating patients on medication usage, help manage complexity and affordability
    • Monitoring -- educating disease-specific self-monitoring, addressing appropriate home monitoring
    • Nutrition – teaching disease appropriate diet and weight management strategies
    • Health Behaviors – educating on support programs, regular physical activity, and modifiable risk factors (e.g., weight, smoking)
    • Goals of Care -- assisting with completion of goals of care/advance directive/MOLST

    Read more about their amazing work with real JMAP patients on our testimonials page. Care managers are linked to practice sites and are available for any patients who qualify for these services.

  • JMAP health behavioral specialists are trained, licensed and certified social workers who ensure that patients within JMAP have access to mental health services. Services provided include:

    • Behavioral health assessment, treatment planning, safety planning, identifying coping strategies, solution focused interventions, short term brief therapy and when appropriate long-term therapy.
    • Practical problem-solving techniques, CBT (Cognitive Behavioral Treatment) & MI (Motivational Interviewing) approaches, with the focus of intervention being to assist patients with their identified treatment goals and improving their overall health outcomes
    • Coordination of care for mental health & substance use services to be received outside of the primary care clinic
    • Psychiatric evaluation for identified patients and psychiatric consultation to providers
  • Community Health Workers (CHWs) are non-clinical staff who possess a unique knowledge and understanding of the community they serve. The CHW serves as a link between healthcare services and the community to facilitate access to resources to improve the quality and cultural competence of service delivery. CHWs focus on building relationships and trust while working to address the social determinants of health that impact our patient’s ability to maintain and improve their health and well-being. CHWs work closely with and are an integral part of the care team.  Services provided may include:  connection to community resources for housing, transportation and food/nutrition programs; assistance with completing benefits applications for resources; and help with health system navigation. CHWs also conduct home visits and engage in community events.

  • JMAP population health pharmacists are clinically trained pharmacists who hold a doctorate of pharmacy. They can perform a variety of tasks for JMAP patients, including making sure patients are not taking unnecessary medications; helping physicians treat their patients with the most cost-effective medicines; reviewing prescriptions for potential drug-drug interactions; assisting physicians with dose titration protocols (so that patients can get necessary medication adjustments without requiring a full doctor's visit); educating patients about the drugs they take and how to take them; and assisting the JMAP quality team with documenting the quality of care in the JMAP population.

  • Appointment access teams help JMAP physicians coordinate urgent appointments with world-class Johns Hopkins specialists when patients have medically urgent needs. This results in care that is both more convenient and less costly for patients and for Medicare.

  • JMAP supports patients through additional services, such as providing transportation to medical appointments or other health-related services, nutrition support (including medically tailored meals as appropriate), resources to allow independent living at home (including through the CAPABLE program) and other financial “bridge” support to help address gaps in available resources, such as compression socks, adult incontinence products, inhaler spacers and items that facilitate independent living.

Value-Added Services

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

  • JMAP's Quality and Transformation team has extensive clinical, quality, EHR, analytic, and programmatic expertise, and produces dashboards to monitor performance, provides program guidance, and facilitates improvement. The team applies Lean Sigma quality improvement tools to promote efficient and effective use of resources, and to improve the quality of care and health outcomes. Using continuous quality improvement (CQI) framework, the team collaborates with partner practices and leadership to identify opportunities for focus, and streamline workflows that improve care and optimize performance in key program metrics. The team identifies and shares best practices, analyzes strengths and opportunities, provides recommendations for priorities, and aids in applying interventions.

  • JMAP's legal and compliance teams employ both internal and external teams of lawyers, tasked with making sure that all JMAP patient data is safe and that all JMAP physician practices and partners know what they need to do to comply with Medicare regulations. These services allow our independent physician practice partners to engage in value-based innovation without the administrative burdens and costs of going it alone.

  • JMAP's communications and marketing team brings a professional touch to producing materials for patients, physicians and caregivers. Notable examples include JMAP's care coordination testimonials and this website. By pooling resources together, JMAP physicians help themselves and their patients to gain access to higher quality care than they could afford on their own.

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