Case Study: Johns Hopkins Community Health Partnership: A model for transformation.
To address the challenging health care needs of the population served by an urban academic medical center, we developed the Johns Hopkins Community Health Partnership (J-CHiP), a novel care coordination program that provides services in homes, community clinics, acute care hospitals, emergency departments, and skilled nursing facilities. This case study describes a comprehensive program that includes: a community-based intervention using multidisciplinary care teams that work closely with the patient's primary care provider; an acute care intervention bundle with collaborative team-based care; and a skilled nursing facility intervention emphasizing standardized transitions and targeted use of care pathways. The program seeks to improve clinical care within and across settings, to address the non-clinical determinants of health, and to ultimately improve healthcare utilization and costs. The case study introduces: a) main program features including rationale, goals, intervention design, and partnership development; b) illness burden and social barriers of the population contributing to care challenges and opportunities; and c) lessons learned with steps that have been taken to engage both patients and providers more actively in the care model. Urban health systems, including academic medical centers, must continue to innovate in care delivery through programs like J-CHiP to meet the needs of their patients and communities.
Johns Hopkins University School of Medicine, United States. Electronic address: Sberkow3@jhmi.edu.
Scott A
SA
Berkowitz
Johns Hopkins Healthcare, United States.
Patricia
P
Brown
Johns Hopkins University School of Medicine, United States.
Daniel J
DJ
Brotman
Johns Hopkins Health System, United States.
Amy
A
Deutschendorf
Johns Hopkins Healthcare, United States.
Linda
L
Dunbar
Johns Hopkins University School of Medicine, United States.
Anita
A
Everett
Sisters Together and Reaching, United States.
Debra
D
Hickman
Johns Hopkins University School of Medicine, United States.
Eric
E
Howell
Men and Families Center, United States.
Leon
L
Purnell
Johns Hopkins Health System, United States.
Carol
C
Sylvester
Johns Hopkins Community Physicians, United States.
Ray
R
Zollinger
Johns Hopkins University School of Medicine, United States.
Michele
M
Bellantoni
Johns Hopkins University School of Medicine, United States.
Samuel C
SC
Durso
Johns Hopkins University School of Medicine, United States.
Constantine
C
Lyketsos
Johns Hopkins University School of Medicine, United States.
Paul
P
Rothman
D000046:Academic Medical Centers; D000328:Adult; D000368:Aged; D015142:Baltimore; D018672:Community Health Planning; D003153:Community Health Services; D003299:Cooperative Behavior; D003695:Delivery of Health Care / Q000191:economics / Q000458:organization & administration*; D005260:Female; D006786:Hospitals, Urban; D006801:Humans; D008297:Male; D008875:Middle Aged; D019982:Organizational Case Studies; D018802:Patient-Centered Care; D011320:Primary Health Care; D019037:Urban Health Services