Presentation is loading. Please wait.

Presentation is loading. Please wait.

Johns Hopkins Community Health Partnership (J-CHiP) December 18, 2012.

Similar presentations


Presentation on theme: "Johns Hopkins Community Health Partnership (J-CHiP) December 18, 2012."— Presentation transcript:

1 Johns Hopkins Community Health Partnership (J-CHiP) December 18, 2012

2 On January 27th, JHM submitted a $30M proposal in response to a CMMI funding opportunity, to create J- CHiP that spans the care continuum: Community Ambulatory Clinics Emergency Departments Hospitals Skilled Nursing Facilities Mid-May, JHM given 72 hrs to reduce $30M->$20M and address many programmatic issues. On June 15 th, J-CHiP announced CMMI recipient. What is J-CHiP? 2

3 Simple Summary: J-CHiP J-CHiP Program focused on care coordination. 2 Target Populations: a.By year 3, nearly all 40,000 patients discharged annually from JHH and JHBMC and thousands of ED visits may be impacted. b.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: a.Acute/Post-acute/ED: Nearly all JHH/JHBMC discharges/visits. b.Ambulatory/Community Care: JHM clinic sites (and 1 Baltimore Medical System site) within or close to the 7 zip codes. c.Skilled Nursing Facilities (SNFs): Partnerships with 5 neighboring SNFs and JHBMC Care Center for all JHH/JHBMC discharges. 3

4 Community Component Primary Care Sites JHCP: –EBMC –Bayview GIM –JHCP Dundalk –Wyman Park –White Marsh –Canton Crossing –Glen Burnie –Greenspring Other JHM: –Comprehensive Care Practice –JHOC –Beacham Clinic Baltimore Medical System: –Highlandtown Red=PP and Medicare Green=Medicare only Orange=Unclear 4

5 Projected 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. 5

6 Population we will serve (Data represents Priority Partners only…for the start of the program) Characteristics of high-risk group: 47% have 1 or more hospital admissions during Nov Oct ,117 total admissions Total cost care is $30 Million Average of $29,679 per person per year Characteristics of low and moderate risk Group: 6% have one admission Total cost of care is $29 Million Average of $5,463 per person per year 76% of all admissions are accounted for by the high risk group High Complexity 1000 people at six clinics Moderate and Low Complexity 5,258 people at six clinics 84% of Priority Partners Top 16% of Priority Partners Total Population PP at the six clinics 6,258 Average age 49 73% women 6

7 J-CHiP Community: Patient Characteristics High Risk Group = 1000 patients Patient characteristics: Medical and Behavioral Conditions 36% have 6 or more chronic conditions. Heart disease: 98% –End-organ conditions »Coronary Artery Disease (condition leading to heart attack): 58% »Heart Failure: 32% –Modifiable risk factors »Hypertension: 84% »Smoking: 71% »High Levels of Cholesterol : 52% Lung disease –Asthma: 42% –Emphysema: 29% Kidney disease: 28% Substance use –Smoking: 71% –Substance abuse: 45% –Alcohol Abuse: 29% Diabetes: 49% 7

8 Target Population Attend one of the participating clinics in/ near the 7 zip codes Member identified to be in the top 20% of people with a high risk of inpatient admission or ED Visit Outreached by Clinic Staff to make appointment to visit Primary Care doctor and Nurse Case Manager Nurse Case Manager Visit at clinic to complete survey of health and behavioral needs Visit with PCP and team at clinic to work on a Care Plan to identify goals and health care services needs 1.Improved Health care 2.Improved Experience with Healthcare system 3.Reduced Costs of Care BEGIN The JCHiP Journey for Community Members (Priority Partners Medicaid and Medicare) Community Health Worker or Community Support Specialist outreaches to identify barriers to getting Healthcare services Community Health Worker or Community Support Specialist outreaches to identify barriers to getting Healthcare services Ongoing relationship with team members in the clinic and community Ongoing relationship with team members in the clinic and community Referral to members of the JCHiP Team for self- management education, behavioral support, or specialty care 8

9 The JCHiP Team Clinic Based Team 30 Nurse Case Managers embedded at about 10 clinics when responsible for –Initial Assessment and Survey –Ongoing Self-management support –Develops and Communicates Care Plan with member and clinic team 14 Behavioral Specialists (Licensed Clinical Social Workers and Counselors) –Responsible for expedited referrals for mental health and addictions services –Provides behavior change counseling in clinic Primary Care Physician Community Team 40 Community Health Workers responsible for: –Location and engagement of patients who are eligible for JCHiP –Barrier identification and mitigation –Adherence Support (reminders, on- going assessment, coordination) –Focused health education –Social support: support groups. Participate in the organization of volunteer-based support 9

10 Community Leadership Refine the JCHiP community intervention Identify staff for JCHiP from the community Engage community assets to further enhance the project Provide ongoing input regarding the implementation, oversight, and improvement of the project by helping to design and participating on the Community Advisory Board Help craft a sustainability plan for when grant funding ends 10

11 CMS 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. 11


Download ppt "Johns Hopkins Community Health Partnership (J-CHiP) December 18, 2012."

Similar presentations


Ads by Google