The Johns Hopkins Medicine Alliance for Patients (JMAP) aims to improve healthcare quality and the care experience for patients. Our teams work together to deliver the best care to the populations we serve.

If you see a primary care physician at one of our participating provider groups, then you are likely a JMAP patient, unless you are part of a Medicare Advantage Plan. This means that we are already working closely with your doctor to ensure that you get better-coordinated care and an enhanced experience.

If you want more information on how to better access the services described above, talk with your primary care physician.

If your doctors participate in JMAP you will receive better and more coordinated care over time. This is because health care providers will have access to some of your health information from Medicare. This information helps your doctor and other providers track the services you have already gotten, understand where you may need more care, and find ways to facilitate key events in your health care, such as when you transfer in or out of a hospital or when you decide to switch between doctors.

Over time, if you see a doctor or health care provider participating in JMAP, you may notice that:

• You do not have to fill out as many medical forms that ask for the same information
• You do not need to repeat medical tests because your results are shared among your health care team
• The health care providers that you see all know what is going on with your health because they communicate with each other
• The providers participating in JMAP will work with you to make sure the care decisions reflect your preferences and goals

JMAP will improve your care and health outcomes as your care team does more to follow your health, makes sure you get the best care possible, and provides access to special services. At no cost, you will receive a variety of supports, tools, and services specifically designed for patients like you, and specifically tailored to your personal health needs. These represent a holistic approach to see you as a whole person, whose health depends on a variety of factors not often recognized by the health care system. The supports JMAP provides should:

• Make it easier to stay healthy
  Our care coordinators are available to work closely with you to assess your health and financial needs, coordinate your care, and work with you to ensure you are making progress on your health goals.
• Give you fast access to world-class specialists
  Our access specialists are available to help if your doctor thinks that you need rapid access to a specialist (within 48 hours), and the JMAP network contains some of the world’s best specialists.
• Make taking your medicines simple, safe, and effective
  Our pharmacists are available to work with your physician to review your records and make sure that you are only taking the medicines that you really need, and that the ones you are taking are the best combination for your conditions and age group.
• Focus on your mind as well as your body
  Our health behavioral specialists can help you navigate the sometimes confusing process of getting “plugged in” to supportive services to help with anxiety, stress, depression, low mood, quitting smoking, alcohol or drug treatment, and more.
• Help by supporting you and your family
  We have an extensive set of tools and services that help family members support their Medicare-aged loved ones and dependents. Additionally, we actively seek input and feedback about our services to Medicare patients from our Beneficiary Advisory Council, a volunteer group of JMAP patients.

JMAP defines “value” as the things that matter most to each patient.  And the only way we can know that is by asking our patients. Because we listen, our physicians deliver more personalized healthcare and help patients achieve their goals. These goals often include non-medical aspects of care, such a desire to achieve lower out-of-pocket costs and to wait less for seeing certain specialists. Some examples of ways JMAP can improve value to you include:

• Empowering patients
  JMAP physician practices and care coordinators are specifically trained to engage and partner with their Medicare patients, to ensure that you and the care team are working towards the goals that you value most.
• Getting the best medicines for your money
  Our pharmacists can work with both you and your doctor to make sure you are on the most affordable medicines that are best for your condition and age group. Ask your JMAP primary care physician if you might benefit from this service.  
• Avoiding unnecessary tests and services
  Through using Medicare data and our state-of-the-art information systems, we improve coordination and communication among your doctors and make it so that you only get the tests that you need. For example, we do our best to make sure that nothing is ever done twice unless it truly needs repeating.

Edward Tucker has had both of his legs amputated. He relies on wheelchairs to get around his house.

The wheelchair that he uses upstairs is worn out. It's falling apart, and Edward needs a new one. But getting one has been a nightmare. Edward and his wife Dorothy ran into roadblocks with every effort they made.

Then they started working with Care Manager Pat Kearney, who has taken over making phone calls and setting up needed evaluations.

"Pat has been very helpful in running interference," Dorothy explained. "In the past, when things have not run well, agencies and individuals have seen and heard a lot from me, sometimes pleasant, sometimes not so much. That's, unfortunately, what it takes to get things done. That's been my reality. So she's out there getting battered and I say thank you so much."

The system has been so difficult that even with Pat, the Tuckers are having a hard time getting their wheelchair. They know it will eventually come, but for Dorothy, Pat's ability to do the legwork has saved her time, energy, and stress.

"I would be making all of those calls. It would be very stressful and very involved," Dorothy said. "Pat at least has the advantage of introducing herself as part of the system. I, on the other hand, would be presenting myself as a very angry partner of a patient."

From her experience, care management is something all patients should have. "It's essential. It really is. It should be universal for patient care," Dorothy said. "I believe highly in case management."

Nicholas Houman had been admitted to the hospital several times for pneumonia. Doctors prescribed a medication that would help, but the co-pay was $400. Nicholas and his wife Brenda simply could not afford it. The specific medication was the only one that would help Nicholas.

“The doctor said he really needed that because it could stop the pneumonia from coming back,” Brenda said.

Fortunately, they had a care manager on their side. Theresa Messer worked to get the medication cost reduced to a much lower co-pay that the Houmans could afford. Nicholas’ cardiovascular health has been much improved, and he has not had any complications with pneumonia since taking the medication.

“It really has made a big difference,” Brenda said. “A really big difference. We never would have been able to do that without Theresa’s help.”

Theresa also helped Nicholas get a voucher for free eye glasses and has helped him see the doctor right away when the couple was worried about his health after a surgery.

“If I need anything or just need some reassurance that everything’s okay, all I have to do is call her,” Brenda said. “And she may not be at her desk, but she calls me back the same day, and I mean the exact same day.”

Care managers are available to Medicare members at participating JHCP locations, as well as Columbia Medical Practice, Potomac Physicians and Cardiovascular Specialists of Central Maryland. If you think a care manager could help you, talk to your doctor.

Dana Irby had a problem. He was in need of a machine to help him breathe in his sleep, but he did not know what to do to get it. He felt stuck.

So Dana found Wondella, a care manager at JHCP Wyman Park.

“I didn’t know what to do,” Dana said. “So I just knocked on her door one day and I said, ‘Can you help me? I have a problem.’”

As a care manager, Wondella’s job is to help patients like Dana. Where he felt stuck, Wondella knew what needed to be done to get his device.

“I stepped in to help him navigate the system, because not only do you have to identify the vendor, but you also have to make sure the necessary paperwork is in to make sure those supplies are sent to the patient,” she explained.

Dana got the breathing machine. Now, he always knows that Wondella is there for anything else he might need.

“If I have a problem where I feel as though it’s gridlocked, I won’t hesitate to call her at all,” Dana said. “If I have a problem, I’ll call her.”

Care managers are available to Medicare members at participating JHCP locations, as well as Columbia Medical Practice, Potomac Physicians and Cardiovascular Specialists of Central Maryland. If you think that you could benefit from having a care manager, talk to your doctor.

“I’d recommend it strongly,” Dana said. “You never know when you might need somebody in a time of crisis and you don’t know where to turn. That's what they’re there for. And I thank her for all of what she has done for me.”

Marina Thankful for 'Excellent' Care Manager Carole

Marina, a patient at Johns Hopkins Community Physicians at Annapolis, is 82 years old, lives alone and lacks a support system nearby. She has bad arthritis and is on a blood thinner. Marina needed some extra help.

Carole Campbell became her care manager in January 2015. Because of her age and health concerns, Marina's needs extended outside the doctor's office. Carole helped get Marina a new bed that is easier for her to change the sheets and has rails so that she won't fall out. Carole set Marina up for the Meals on Wheels program, so that she gets food delivered to her home that is within her strict diet.

Carole made sure that Marina's taxi vouchers were in order so that she could get to her appointments. She has given Marina advice on how to stay healthy.

"All the advice that she is giving me is excellent," Marina said. "I follow the instructions that she gives me and I feel much better. And she helps me not just with my illness, but I feel like somebody cares - that when I talk, she listens to me. And that's what I love - that she listens to me."

Marina also has a language barrier. She is a native Guatemalan with a noticeable accent. Carole has made many phone calls and referrals for her. Now, Carole is working to get Marina a type of walker that would make it easider and more comfortable for her to get around.

"I say thank God that I have somebody that cares," Marina said. "She really is excellent. She's patient, she's sweet, she listens. Everything. What else could I ask for?"

Care managers are available to Medicare members at participating JHCP locations, as well as Columbia Medical Practice, Potomac Physicians and Cardiovascular Specialists of Central Maryland. If you think that a care manager could help you be healthier, talk to your provider.

Water's Edge Patients Guided Through Traumatic Event

On Dec. 19, 2014, Patrick Reardon had surgery to remove one of his kidneys that had cancer on it. The surgery went well, but three days later, Patrick suffered a massive bleed-out.

Doctors stopped the bleeding, saving his life. He was hospitalized again and placed on a ventilator.

"After that, for two months, I couldn't tell you what was going on or what happened," Patrick said.

That left Patrick's wife, Sharon, to figure out his medical decisions. Sharon, even with the help of the couple's daughters, couldn't do it alone. Patrick's doctor referred to couple to Kathy Eikenberg, a care manager at Johns Hopkins Community Physician's at Water's Edge.

Kathy talked through Patrick's recovery options with Sharon and helped them get Patrick into the rehabilitation unit at Johns Hopkins Bayview Medical Center.

"Kathy, amazingly, had been on the very unit that we were hoping to get into, and she assured me that, if he did qualify for that, then we would be in really good hands and not moving all around the area," Sharon said.

Patrick is doing better now, and both he and Sharon recommend the care management program to anyone.

"I have never been so carried through a traumatic event as this new field of care management provides," Sharon said. "It helps not only the patient, but really the entire family. And even the after-care, when you are going through recovery, it flows right through the whole situation. I don't know how I would have gotten through without her, even though I didn't know she was going to be there," she added.

Care managers are available to Medicare members at participating JHCP locations, as well as Columbia Medical Practice, Potomac Physicians and Cardiovascular Specialists of Central Maryland. If you think that a care manager could help you be healthier, talk to your provider.