Johns Hopkins launched a care coordination program that boosted outcomes and saved millions in care costs for some of Baltimore’s most vulnerable patients.
The Johns Hopkins Community Health Partnership (J-CHiP) is a care coordination program with two central elements: a set of acute care interventions, which were piloted in two of the city’s hospitals, and a community-based care management piece based primarily in ambulatory care settings, according to a study published in JAMA Network Open.
The acute care interventions were put in place across 35 adult inpatient units and aren't targeted to a specific payer population, so it was open to Medicare, Medicaid and commercially insured patients. Elements include a focus on medication management, multidisciplinary rounds and follow-up calls, in addition to improved transitions to skilled nursing or other post-acute care facilities for patients that need it.
Meanwhile, the community interventions aim for the highest-risk patients and address their barriers to care access, such as an inability to go to a doctor's office. Behavioral health care is also embedded into this.
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J-CHiP launched in 2012 and ended its initial pilot in 2016. More than 2,100 patients enrolled in the community initiative, and in that window saved $24.4 million in healthcare costs and reduced 30-day readmissions by 36 per 1,000 beneficiary episodes.
The acute care interventions saved $29.2 million, while 30-day readmissions increased by 14 per 1,000 episodes. Scott Berkowitz, M.D., associate professor at Johns Hopkins and the study’s lead author, told FierceHealthcare that the cost savings were something the team “couldn’t possibly have anticipated,” though they did set benchmark goals for the study.
He noted that there’s room for improvement and for the program to evolve, however. Emergency department visits decreased by 51 per 1,000 episodes, for example, as result for which there’s room to grow.
"I think that some of the other results were mixed, … so we’re cognizant of that and trying to learn from that,” Berkowitz said.
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Providers that want to learn from Johns Hopkins’ model need to first have a complete picture of what their local communities need. Not every urban hospital is in a region with the same challenges as Baltimore, and facilities in more rural areas can also take advantage of community partnerships, Berkowitz said.
Johns Hopkins also needed a large, diverse team to make J-CHiP work, he said. The system hired 100 new care team members, and hundreds of others were involved in the program. It also required buy-in from the top down, with active leadership involvement.
The health system also worked with a variety of energized community partners, from nonprofit organizations to skilled nursing facilities to behavioral health providers. Having all those voices involved was critical, Berkowitz said.
“It takes that sort of full leadership buy-in and full involvement of an organization to try and do this type of change we’re talking about,” he said.