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

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• 作者：Scott A. Berkowitz^a ; ^{Sberkow3@jhmi.edu} ; Patricia Brown^b ; Daniel J. Brotman^a ; Amy Deutschendorf^c ; Linda Dunbar^b ; Anita Everett^a ; Debra Hickman^d ; Eric Howell^a ; Leon Purnell^e ; Carol Sylvester^c ; Ray Zollinger^f ; Michele Bellantoni^a ; Samuel C. Durso^a ; Constantine Lyketsos^a ; Paul Rothman^a ; On behalf of the J-CHiP ProgramEric B. Bass ; William Baumgartner ; Michele Bellantoni ; Scott A. Berkowitz ; Romsai Tony Boonyasai ; Daniel Brotman ; Patricia Brown ; Amy Deutschendorf ; Linda Dunbar ; Samuel C. Durso ; Anita Everett ; Michael Fingerhood ; Kevin Frick ; Peter Greene ; Lindsay Hebert ; David Hellmann ; Debra Hickman ; Douglas E. Hough ; Eric Howell ; Xuan Huang ; Chidinma Ibe ; Sarah Kachur ; Anne Langley ; Diane Lepley ; Curtis Leung ; Constantine Lyketsos ; Yanyan Lu ; Shannon Murphy ; Mary Myers ; Tracy Novak ; Kymberlee Olson ; Leon Purnell ; Stephanie Reel ; Judy Reitz ; Melissa Richardson ; Regina Richardson ; Mike Rogers ; Paul Rothman ; Carol Sylvester ; Martha Sylvia ; Albert W. Wu ; Hunter Young ; Roy Ziegelstein ; Ray Zollinger
• 刊名：Healthcare
• 出版年：2016
• 出版时间：December 2016
• 年：2016
• 卷：4
• 期：4
• 页码：264-270
• 全文大小：828 K
• 卷排序：4

文摘

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.