Johns Hopkins Community Health Partnership

Johns Hopkins Community Health Partnership


Here’s what we all know. Too many people are getting sicker, instead of better, after they leave the hospital. And what’s crazy is… a lot
of it is preventable. There are things we can all do.
Caregivers… patients… families… The first step is to admit
that it won’t get better if we keep doing the same thing. Because that would be crazy. At Johns Hopkins Medicine, we’ve
been working at this for a while. So it’s interesting, the Community
Health Partnership has really been in many smaller ways things that Hopkins physicians
and nurses and healthcare professionals have been working on for years.
For example the Aliki Initiative has been able to improve the perceived satisfaction
by patients of the care they’re providing and also it would show the reduction
in readmissions due specifically to congestive heart failure. There’s been an in-patient group working
to reduce readmissions and they’ve been able to successfully reduce readmissions
in multiple pilot units at both Johns Hopkins Hospital and Johns Hopkins Bayview. If we are doing a good job at communicating,
at coordinating care we’ll have less of a problem with patients
needing unneeded care such as readmissions to the hospital, such as emergency room visits.
These are activities that are bad for patients, demoralizing for their families, and are wasting healthcare resources. J-CHiP is intended to improve on that. The goal of the Johns Hopkins Community
Health Partnership is really to improve the quality of care that we provide to our
patients while maintaining and reducing healthcare cost. Before the Community Health Partnership
arose on the acute care side we recognized that we needed to be doing a better job
and having a more concerted effort towards communicating with patients and their families
and outpatient providers about the care of their patients. So there have been a number of tools that
we’ve developed that help to make sure that outpatient providers are informed
about the in-patient hospitalization, electronic tools that help providers communicate
even when they don’t have electronic records that are
shared by Johns Hopkins. We also have used technology to improve
education of patients so we have tablet-based education curricula that even
people who have no computer literacy can use because it’s just a matter of pushing
the button on the screen to hear about important information about your
disease or your new medications. We’ve had efforts at identifying in real
time when patients are being readmitted to the hospital and alerting the providers to
discharge those patients so that we can learn from our own readmissions. The new Community Health Partnership
is funded through a CMS grant, one of the largest grants given at almost $20 million
and that’s going to allow us really to invest in the infrastructure that can help
bring many of those people together that had been working to improve health before
and it’s going to really allow us to do it on a scale that we’ve never seen before at Hopkins. One of the most innovative aspects
is our transition guides. Transition guides are healthcare professionals
that will be a link between patients in the healthcare system and are
going to really be based in the community and outside of the hospital. I’m confused.
I understand because you have a lot. How many times do you take this one today? Once a day.
It should be twice a day. I was trying to stretch it out.
It’s expensive. Another group we’re recruiting and hiring
for are community health workers and they’re really people that are integrated
already into the neighborhoods that are part of the local community that are more
aligned with what our patients and their neighborhoods have been doing but they’re
going to also be a bridge to the healthcare system so that we can try and
bring resources needed to patients directly into their neighborhood, giving them an access to resources to improve
their health, to change behaviors so that they may be able to do things like stop
smoking where they haven’t been able to before, that we’ll be able to prevent
those unnecessary hospitalizations and therefore save money by avoiding
that type of spending. The idea also is to improve health so
if you’re healthier you don’t need to use healthcare resources. The Community Health Partnership we hope
will be a model for other academic medical centers to follow.
If we’re able to fully implement J-CHiP in a way that is providing us the data we
need to create generalizable knowledge. We are excited that we’ll be able to show
the nation how care can be coordinated in a way that can help patients
from all walks of life.

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