Presentation on theme: "Johns Hopkins Community Health Partnership (“J-CHiP”)"— Presentation transcript:
1Johns Hopkins Community Health Partnership (“J-CHiP”) December 18, 2012
2What is J-CHiP?On January 27th, JHM submitted a $30M proposal in response to a CMMI funding opportunity, to create “J-CHiP” that spans the care continuum:CommunityAmbulatory ClinicsEmergency DepartmentsHospitalsSkilled Nursing FacilitiesMid-May, JHM given 72 hrs to reduce $30M->$20M and address many programmatic issues.On June 15th, J-CHiP announced CMMI recipient.
3Simple Summary: J-CHiP 1..2..3 1 J-CHiP Program focused on care coordination.2 Target Populations:By year 3, nearly all 40,000 patients discharged annually from JHH and JHBMC and thousands of ED visits may be impacted.Underserved, high risk East Baltimore population in 7 zip codes around JHH & JHBMC ≈ 1000 Priority Partners MCO and 2000 FFS Medicare patients at high risk for utilization.3 Primary Components of Care Continuum:Acute/Post-acute/ED: Nearly all JHH/JHBMC discharges/visits.Ambulatory/Community Care: JHM clinic sites (and 1 Baltimore Medical System site) within or close to the 7 zip codes.Skilled Nursing Facilities (SNFs): Partnerships with 5 neighboring SNFs and JHBMC Care Center for all JHH/JHBMC discharges.
4Community Component Primary Care Sites Other JHM:Comprehensive Care PracticeJHOCBeacham ClinicBaltimore Medical System:HighlandtownJHCP:EBMCBayview GIMJHCP DundalkWyman ParkWhite MarshCanton CrossingGlen BurnieGreenspringRed=PP and MedicareGreen=Medicare onlyOrange=Unclear
5Projected Program Impact Achieve the “Triple Aim” of improved health and experience with the healthcare system, and reduced costs of healthcare for the highest risk patients in East Baltimore across all levels of care (community, clinic, ED, hospital, nursing home).Create about 80 innovative healthcare jobs.Forge durable community alliances.
676% of all admissions are accounted for Population we will serve (Data represents Priority Partners only…for the start of the program)Total Population PP at the six clinics6,258Average age 4973% womenCharacteristics of high-risk group:47% have 1 or more hospital admissions during Nov Oct 20121,117 total admissionsTotal cost care is $30 MillionAverage of $29,679 per person per yearCharacteristics of low and moderate risk Group:6% have one admissionTotal cost of care is $29 MillionAverage of $5,463 per person per year76% of all admissions are accounted forby the high risk groupHighComplexity1000 people atsix clinicsModerate and Low Complexity5,258 people at six clinicsTop 16% of Priority Partners84% of Priority Partners
7J-CHiP Community: Patient Characteristics High Risk Group = 1000 patientsPatient characteristics: Medical and Behavioral Conditions36% have 6 or more chronic conditions.Lung diseaseAsthma: 42%Emphysema: 29%Kidney disease: 28%Substance useSmoking: 71%Substance abuse: 45%Alcohol Abuse: 29%Diabetes: 49%Heart disease: 98%End-organ conditionsCoronary Artery Disease (condition leading to heart attack): 58%Heart Failure: 32%Modifiable risk factorsHypertension: 84%Smoking: 71%High Levels of Cholesterol : 52%
8Attend one of the participating clinics in/ near the 7 zip codes The JCHiP Journey for Community Members(Priority Partners Medicaid and Medicare)BEGINTarget PopulationAttend one of the participating clinics in/ near the 7 zip codesImproved Health careImproved Experience with Healthcare systemReduced Costs of CareMember identified to be in the top 20% of people with a high risk of inpatient admission or ED VisitOngoing relationshipwith team members in theclinic and communityOutreached by Clinic Staff to make appointment to visit Primary Care doctor and Nurse Case ManagerReferral to members of the JCHiP Team for self-management education, behavioral support, or specialty careCommunity Health Worker orCommunity Support Specialistoutreaches toidentify barriers to gettingHealthcare servicesVisit with PCP and team at clinic to work on a Care Plan to identify goals and health care services needsNurse Case Manager Visit at clinic to complete survey of health and behavioral needs
9The JCHiP Team Clinic Based Team Community Team 30 Nurse Case Managers embedded at about 10 clinics when responsible forInitial Assessment and SurveyOngoing Self-management supportDevelops and Communicates Care Plan with member and clinic team14 Behavioral Specialists (Licensed Clinical Social Workers and Counselors)Responsible for expedited referrals for mental health and addictions servicesProvides behavior change counseling in clinicPrimary Care PhysicianCommunity Team40 Community Health Workers responsible for:Location and engagement of patients who are eligible for JCHiPBarrier identification and mitigationAdherence Support (reminders, on-going assessment, coordination)Focused health educationSocial support: support groups. Participate in the organization of volunteer-based support
10Community Leadership Refine the JCHiP community intervention Identify staff for JCHiP from the communityEngage community assets to further enhance the projectProvide ongoing input regarding the implementation, oversight, and improvement of the project by helping to design and participating on the Community Advisory BoardHelp craft a sustainability plan for when grant funding ends
11CMS Funding Disclosure The project described was supported by Funding Opportunity Number CMS-1C from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.