Johns Hopkins Community Health Partnership ( “ J-CHiP ” )

1. Johns Hopkins Community Health Partnership (“J-CHiP”) December 18, 2012

2. What is J-CHiP? • On January 27th, JHM submitted a $30M proposal in response to a CMMI funding opportunity, to create “J-CHiP” that spans the care continuum: • Community • Ambulatory Clinics • Emergency Departments • Hospitals • Skilled Nursing Facilities • Mid-May, JHM given 72 hrs to reduce $30M->$20M and address many programmatic issues. • On June 15th, J-CHiP announced CMMI recipient.

3. Simple Summary: J-CHiP 1..2..3 1J-CHiP Program focused on care coordination. 2 Target Populations: • By year 3, nearly all 40,000 patients discharged annually from JHH and JHBMC and thousands of ED visits may be impacted. • Underserved, high risk East Baltimore population in 7 zip codes around JHH & JHBMC  ≈ 1000 Priority Partners MCO and 2000 FFS Medicare patientsat high risk for utilization. 3 Primary Components of Care Continuum: • Acute/Post-acute/ED: Nearly all JHH/JHBMC discharges/visits. • Ambulatory/Community Care: JHM clinic sites (and 1 Baltimore Medical System site) within or close to the 7 zip codes. • Skilled Nursing Facilities (SNFs): Partnerships with 5 neighboring SNFs and JHBMC Care Center for all JHH/JHBMC discharges.

4. Community ComponentPrimary Care Sites • Other JHM: • Comprehensive Care Practice • JHOC • Beacham Clinic • Baltimore Medical System: • Highlandtown • JHCP: • EBMC • Bayview GIM • JHCP Dundalk • Wyman Park • White Marsh • Canton Crossing • Glen Burnie • Greenspring Red=PP and Medicare Green=Medicare only Orange=Unclear

5. Projected Program Impact • Achieve the “Triple Aim” of improved health and experience with the healthcare system, and reduced costs of healthcare for the highest risk patients in East Baltimore across all levels of care (community, clinic, ED, hospital, nursing home). • Create about 80 innovative healthcare jobs. • Forge durable community alliances.

6. Population we will serve(Data represents Priority Partners only…for the start of the program) Total Population PP at the six clinics 6,258 Average age 49 73% women Characteristics of high-risk group: • 47% have 1 or more hospital admissions during Nov 2011- Oct 2012 • 1,117 total admissions • Total cost care is $30 Million • Average of $29,679 per person per year Characteristics of low and moderate risk Group: • 6% have one admission • Total cost of care is $29 Million • Average of $5,463 per person per year 76% of all admissions are accounted for by the high risk group Top 16% of Priority Partners 84% of Priority Partners

7. J-CHiP Community: Patient Characteristics High Risk Group = 1000 patients Patient characteristics: Medical and Behavioral Conditions 36% have 6 or more chronic conditions. • Lung disease • Asthma: 42% • Emphysema: 29% • Kidney disease: 28% • Substance use • Smoking: 71% • Substance abuse: 45% • Alcohol Abuse: 29% • Diabetes: 49% • Heart disease: 98% • End-organ conditions • Coronary Artery Disease (condition leading to heart attack): 58% • Heart Failure: 32% • Modifiable risk factors • Hypertension: 84% • Smoking: 71% • High Levels of Cholesterol :52%

8. The JCHiP Journey for Community Members (Priority Partners Medicaid and Medicare) BEGIN Target Population Attend one of the participating clinics in/ near the 7 zip codes Member identified to be in the top 20% of people with a high risk of inpatient admission or ED Visit Improved Health care Improved Experience with Healthcare system Reduced Costs of Care Ongoing relationship with team members in the clinic and community Outreached by Clinic Staff to make appointment to visit Primary Care doctor and Nurse Case Manager Referral to members of the JCHiP Team for self-management education, behavioral support, or specialty care Community Health Worker or Community Support Specialist outreaches to identify barriers to getting Healthcare services Visit with PCP and team at clinic to work on a Care Plan to identify goals and health care services needs Nurse Case Manager Visit at clinic to complete survey of health and behavioral needs

9. The JCHiP Team Clinic Based Team • 30 Nurse Case Managers embedded at about 10 clinics when responsible for • Initial Assessment and Survey • Ongoing Self-management support • Develops and Communicates Care Plan with member and clinic team • 14 Behavioral Specialists (Licensed Clinical Social Workers and Counselors) • Responsible for expedited referrals for mental health and addictions services • Provides behavior change counseling in clinic • Primary Care Physician Community Team • 40 Community Health Workers responsible for: • Location and engagement of patients who are eligible for JCHiP • Barrier identification and mitigation • Adherence Support (reminders, on-going assessment, coordination) • Focused health education • Social support: support groups. Participate in the organization of volunteer-based support

10. Community Leadership • Refine the JCHiP community intervention • Identify staff for JCHiP from the community • Engage community assets to further enhance the project • Provide ongoing input regarding the implementation, oversight, and improvement of the project by helping to design and participating on the Community Advisory Board • Help craft a sustainability plan for when grant funding ends

11. CMS Funding Disclosure The project described was supported by Funding Opportunity Number CMS-1C1-12-0001 from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation.  Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.