Case Study: Johns Hopkins Community Health Partnership: A model for transformation

Published: December 31, 2016
Category: Bibliography
Authors: Amy Deutschendorf, Anita Everett, Carol Sylvester, Constantine Lyketsos, Daniel J. Brotman, Debra Hickman, Eric Howell, Leon Purnell, Linda Dunbar, Michele Bellantoni, Patricia Brown, Paul Rothman, Ray Zollinger, Samuel C. Durso, Scott A.Berkowitz
Countries: United States
Language: English
Types: Acute care intervention, Care coordination, Care Management, Population Health
Settings: Health Plan, Hospital, Specialist


To address the challenging health care needs of the population served by an urban academic medical center, we developed the Johns Hopkins Community Health Partnership (J-CHiP), a novel care coordination program that provides services in homes, community clinics, acute care hospitals, emergency departments, and skilled nursing facilities. 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.

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