Implementation of a comprehensive program to improve coordination of care in an urban academic health care system
Journal of Health Organization and Management
ISSN: 1477-7266
Article publication date: 10 August 2018
Issue publication date: 3 September 2018
Abstract
Purpose
Academic healthcare systems face great challenges in coordinating services across a continuum of care that spans hospital, community providers, home and chronic care facilities. The Johns Hopkins Community Health Partnership (J-CHiP) was created to improve coordination of acute, sub-acute and ambulatory care for patients, and improve the health of high-risk patients in surrounding neighborhoods. The paper aims to discuss this issue.
Design/methodology/approach
J-CHiP targeted adults admitted to the Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, patients discharged to participating skilled nursing facilities (SNFs), and high-risk Medicare and Medicaid patients receiving primary care in eight nearby outpatient sites. The primary drivers of the program were redesigned acute care delivery, seamless transitions of care and deployment of community care teams.
Findings
Acute care interventions included risk screening, multidisciplinary care planning, pharmacist-driven medication management, patient/family education, communication with next provider and care coordination protocols for common conditions. Transition interventions included post-discharge health plans, hand-offs and follow-up with primary care providers, Transition Guides, a patient access line and collaboration with SNFs. Community interventions involved forming multidisciplinary care coordination teams, integrated behavioral care and new partnerships with community-based organizations.
Originality/value
This paper offers a detailed description of the design and implementation of a complex program to improve care coordination for high-risk patients in an urban setting. The case studies feature findings from each intervention that promoted patient engagement, strengthened collaboration with community-based organizations and improved coordination of care.
Keywords
Acknowledgements
The authors wish to acknowledge the late Dr Fred Brancati, who was a major contributor to the launch of the J-CHiP program. The authors thank the leaders of the Johns Hopkins Community Health Partnership who agreed to be interviewed for the case studies, and acknowledge the generous institutional support provided by JHM in creating the J-CHiP program. The project described was supported by Grant number 1C1CMS331053 from the Department of Health and Human Services, CMS. The Johns Hopkins Community Health Partnership Team includes: Executive Board: Patricia M.C. Brown, Paul B. Rothman, Scott A. Berkowitz, William Baumgartner, Michele Bellantoni, Edward Beranek, Robert Blum, Daniel J. Brotman, John Colmers, Amy Deutschendorf, Linda Dunbar, Samuel C. Durso, Stuart Erdman, Anita Everett, Daniel Ford, Peter Greene, Dalal Haldeman, David Hellmann, Eric E. Howell, Steven Kravet, Constantine G. Lyketsos, Steven Mandell, David Parker, Stephanie Reel, Judy Reitz, Carol Sylvester, Raymond Zollinger; Program Directorship: Paul B. Rothman, Patricia M.C. Brown, Scott A. Berkowitz; Acute Care Leadership Team: Amy Deutschendorf, Daniel Brotman, Eric Howell, Diane Lepley, Melissa Richardson, Carol Sylvester, Romsai Tony Boonyasai, Curtis Leung, Mary Myers; Community Care Leadership Team: Linda Dunbar, Lindsay Andon, Jennifer Bailey, Michael Fingerhood, Lindsay Hebert, Debra Hickman, Sarah Kachur, Anne Langley, Tracy Novak, Michelle Petinga, Leon Purnell, Regina Richardson, Vince Truant, Hunter Young, Raymond Zollinger; Skilled Nursing Facility Leadership Team: Michele Bellantoni, Samuel Chris Durso, Lisa Filbert, Carol Sylvester; Behavioral Health Leadership Team: Constantine G. Lyketsos, Anita Everett, Melissa Reuland, Laura Torres; Cost Savings and Analytic Leadership Team: Shannon M.E. Murphy, Kevin D. Frick, Douglas E. Hough, Martha Sylvia, Sarah Kachur, Yanyan Lu, Xuan Huang; Evaluation Leadership Team: Lawrence Appel, Felicia Hill-Briggs, Lindsay Andon, Nola Durkin, Patti Ephraim, Hsin-Chieh Yeh, Arielle Apfel; Research Facilitating Team: Eric B. Bass, Albert W. Wu, Ya Luan Hsiao, Christine Weston, Lisa Wilson; Communications Leader: Abigail Pulcinella; Human Resources Leader: Linda Dunbar; and Tumaini Team: Chidinma Ibe, Demetrius Frazier, Brian Knight, Mike Rogers, Ernest Smith, Debra Hickman, Leon Purnell.
Disclaimer: The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the US Department of Health and Human Services or any of its agencies. The research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the findings of the independent evaluation contractor.
Citation
Hsiao, Y.L., Bass, E.B., Wu, A.W., Richardson, M.B., Deutschendorf, A., Brotman, D.J., Bellantoni, M., Howell, E.E., Everett, A., Hickman, D., Purnell, L., Zollinger, R., Sylvester, C., Lyketsos, C.G., Dunbar, L. and Berkowitz, S.A. (2018), "Implementation of a comprehensive program to improve coordination of care in an urban academic health care system", Journal of Health Organization and Management, Vol. 32 No. 5, pp. 638-657. https://doi.org/10.1108/JHOM-09-2017-0228
Publisher
:Emerald Publishing Limited
Copyright © 2018, Emerald Publishing Limited