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Care Delivery

Developing, Implementing and Evaluating Models of Primary Care Delivery

Among developed countries, the U.S. ranks low in outcomes and highest in spending. National and international evidence shows healthcare systems with a greater emphasis on primary care have improved outcomes at lower costs. Practitioners and systems delivering primary care shepherd patients through a spectrum of health, wellness, and acute and chronic illnesses. The Consortium studies the existing state of primary care, while working to close gaps identified between current practice and the ideal. We believe concepts in wellness, illness, minimizing physical and mental debility, and maximizing function (spanning the course of a person's life) require greater attention than received in current models.

Recently, Patient-Centered Medical Home (PCMH) became a goal for primary care practice. Focus is on care between office visits, not only on care during the visit, enabling practitioner teams to collaborate and share responsibilities of providing optimal care. Elements of PCMH include:

  • Team-based care.
  • Emphasis on education.
  • Patient engagement.
  • Behavioral medicine.
  • Use of registries to identify patients in need of individualized care.
  • Use of proactive population-based care.
  • Deployment of information technology for tracking, monitoring, and reminding. Dashboards provide timely feedback on care patterns and care quality.

Johns Hopkins Community Health Partnership (J-CHiP)

The Johns Hopkins University School of Medicine collaborating with Johns Hopkins Health System (JHHS) received a $19.9 million grant from the Centers for Medicare & Medicaid Services (CMS). The grant is part of a competitive initiative seeking to identify and support innovative opportunities that improve care delivery, and achieve its three-part aim: Read more

  • Improving the individual experience of care
  • Improving the health of populations
  • Reducing the per capita costs of care for populations.

External Initiatives

Maryland PCMH Demonstration Project offers a new model of primary care with the aim of increasing quality of care and reducing Emergency Department visits and hospitalizations. View complete slide show.