Description

This article describes the Johns Hopkins Community Health Partnership (J-CHiP), a partnership between Johns Hopkins Medicine (JHM) and two grassroots community-based organizations (CBO). J-CHiP is a novel care coordination program that provides services in homes, community clinics, acute care hospitals, emergency departments, and skilled nursing facilities. J-CHiP was formed as a regional approach to transformation supported by a Health Care Innovation Award (HCIA) from the Center for Medicare and Medicaid (CMMI). As partners in this effort, the CBOs receive a portion of the CMMI grant dollars on a contractual basis that has increased over time as the component developed. This case study describes a comprehensive program that includes: a community-based intervention using multidisciplinary care teams that work closely with the patient’s primary care provider; an acute care intervention bundle with collaborative team-based care; and a skilled nursing facility intervention emphasizing standardized transitions and targeted use of care pathways. The program seeks to improve clinical care within and across settings, to address the non-clinical determinants of health, and to ultimately improve healthcare utilization and costs. The case study introduces: a) main program features including rationale, goals, intervention design, and partnership development; b) illness burden and social barriers of the population contributing to care challenges and opportunities; and c) lessons learned with steps that have been taken to engage both patients and providers more actively in the care model. Urban health systems, including academic medical centers, must continue to innovate in care delivery through programs like J-CHiP to meet the needs of their patients and communities.