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December 2014
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J-CHiP, JMAP and the Future of Accountable Care at Johns Hopkins

As health care increasingly focuses on population health, Johns Hopkins Medicine is getting ahead of the curve with two innovative care delivery models.

Scott

Scott Berkowitz, medical director of
accountable care in the Office of Johns
Hopkins Physicians and executive
director of JMAP.

The patient had diabetes, with cellulitis and poor blood sugar control, despite regular doctor visits and insulin prescriptions. Why her blood sugar levels remained stubbornly high was a mystery, says Michael Fingerhood, an internist and addictions medicine specialist who works closely with the Johns Hopkins Community Health Partnership (J-CHiP). It took the combined insights of her J-CHiP care team, which included a community health worker, pharmacist, home care nurse and Fingerhood, to determine the source of the problem, and it took their combined efforts to fix it.

"She couldn't see well enough to draw up the insulin dose and was embarrassed to admit this," he says. "When we put the pieces together, she was prescribed insulin pens and encouraged to see an eye specialist. Three months later, her HbA1C levels had dropped from 10.7 to 8.1, and she had seen the specialist."

Team-based care with an emphasis on care coordination is a hallmark of J-CHiP, as it is with Johns Hopkins Medicine's accountable care organization (ACO), the Johns Hopkins Medicine Alliance for Patients (JMAP). As the Affordable Care Act pushes health systems toward a population health model, Johns Hopkins Medicine is getting ahead of the curve with its two innovative care delivery models.

Launched in January 2014, JMAP is a Medicare Shared Savings ACO, treating Medicare patients, currently numbering 36,000. If JMAP generates savings, it can possibly share up to 50 percent of those savings with physicians. JMAP works with three outside provider practices: Columbia Medical Practice, Potomac Physician Associates and Cardiovascular Specialists of Central Maryland.

J-CHiP, now in its third year, has offered services to a broader population—59,000 people to date, largely in an East Baltimore catchment area—and is funded by a three-year, $19.9 million Centers for Medicare & Medicaid Services grant. Its patients are adults of all ages and include a high-risk cohort of Medicare and Priority Partners (Medicaid) patients, and nearly all adult discharges from The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, irrespective of payer. Like JMAP, it works with entities outside Johns Hopkins, including skilled nursing facilities and community-based organizations, such as the Men and Families Center and Sisters Together And Reaching.

Both JMAP and J-CHiP are accountable for the care of a defined population, aiming to provide the highest-quality team-based care while saving money. Toward those ends, both rely on analytics to identify high-risk patients and monitor cost trends.

Many J-CHiP patients have significant mental health and substance use conditions, says Fingerhood. Keeping them healthy and out of the hospital is not something any one care provider could do on his or her own. But with the entire care team and a case manager—some 2,800 J-CHiP patients are assigned a community health worker for case management—these patients can be reached and their health improved, Fingerhood says. "J-CHiP allows me to do what needs to be done for patients that I can't do in a 15-minute office visit."

"In addition to advancing our strategic priorities of patient- and family-centered care and integration, JMAP and J-CHiP are preparing Johns Hopkins Medicine for the future of medical care," says Scott Berkowitz, a cardiologist who is medical director of accountable care in the Office of Johns Hopkins Physicians and executive director of JMAP.

"With J-CHiP, we're partnering with community-based organizations; JMAP, with three outside provider practices. Such team building outside of the walls of Hopkins is going to be absolutely critical over the next decade."

— Christina DuVernay

 

 
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