Whatever happens to the Patient Protection and Affordable Care Act, the intractable issues it addresses are not going away: fragmented care, health disparities and soaring costs. Improving all three at once is a bold goal, but it is one that The Johns Hopkins Hospital’s After-Care Clinic has tackled, with impressive results.

Directed by internist Rosalyn Stewart and emergency medicine physician Arjun Chanmugam, the clinic has improved the odds that patients who struggle to manage their health will avoid Emergency Department visits or readmission. And in so doing, they have saved the health system more than $1 million while providing a highly vulnerable population with much-needed transitional care.

The concept is straightforward: After treatment in the Emergency Department or after discharge, connect patients with primary care and help them manage their health. But delivering on that mission is a complex task, requiring a multidisciplinary team of primary care providers, nurses, pharmacists and social workers.

The After-Care Clinic is not an urgent care center, nor is it a primary care office, explains Stewart. Rather, it provides a setting where patients can be assessed, treated and transitioned to a community provider.

Patients at high risk of readmission or Emergency Department use are referred to the clinic, located in the Johns Hopkins Outpatient Center, for an appointment within a week. A typical visit lasts 90 minutes, during which time the patient might see a provider for care, a pharmacist for medication review, a nurse for disease education and a social worker for connections to community resources.

“Many of our patients face significant barriers to care. They may have poor health literacy. They may lack secure housing or reliable transportation. Our team helps patients get appropriate follow-up care, and that includes educating them about their condition and addressing their social barriers,” says Stewart, who was recently recognized with a 2016 Johns Hopkins Medicine Clinical Award for Clinicians and Care Teams for Innovations in Care.

Since opening in March 2015, the clinic has seen about 3,000 patients and sharply reduced admissions and Emergency Department visits. Stewart and Chanmugam performed a pre- and post-analysis. The readmission rate for clinic patients before they visited the clinic was 3.7 percent. After, it dropped to 1.1 percent. Over a 13-month period, Stewart says, the clinic avoided some 296 Emergency Department visits and 61 admissions. In all, the clinic saved the health system $1,361,288 in medical costs during that time span.

Over time, adds Stewart, “We want to make the After-Care Clinic an entry point for patients into a medical home that connects them with Johns Hopkins primary care—the place where they can receive comprehensive services and patient education under one roof.”