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

2. What 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:
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 15th, J-CHiP announced CMMI recipient.

3. Simple 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.

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

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.

6. 76% 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 clinics
6,258
Average age 49
73% women
Characteristics of high-risk group:
47% have 1 or more hospital admissions during Nov Oct 2012
1,117 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
Top 16% of Priority Partners
84% of Priority Partners

7. J-CHiP Community: Patient Characteristics
High Risk Group = 1000 patients
Patient characteristics: Medical and Behavioral Conditions
36% have 6 or more chronic conditions.
Lung disease
Asthma: 42%
Emphysema: 29%
Kidney disease: 28%
Substance use
Smoking: 71%
Substance abuse: 45%
Alcohol Abuse: 29%
Diabetes: 49%
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%

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

9. The JCHiP Team Clinic Based Team Community 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

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

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.