A local woman living in public housing was not adhering to medical care and needed thyroid surgery yet was distrustful of male doctors and the medical facility where she received her care. Beyond the health issues, a Johns Hopkins-affiliated community health worker who visited the woman at home noticed something: a significant fire hazard. The woman had electrical extension cords running from a single socket through the house and out the window to a neighbor’s residence. Working with the woman, the health worker got the housing authority to fix the electricity, reassigned the patient to a female medical provider and got her surgery scheduled. With the woman’s health care and housing needs met, she has since graduated from school as a certified medical assistant.

It’s just one of many patient success stories achieved through the Johns Hopkins Community Health Partnership (J-CHiP). The four-year program, completed last year, brought multiple stakeholders together to improve community health and reduce health disparities for those receiving care at The Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center and surrounding areas. Funded with support from a $19.9 million innovation award from the Centers for Medicare and Medicaid Services, the program—which included caregivers at Johns Hopkins; two grass-roots, community-based organizations; and five neighboring skilled nursing facilities—enrolled over 80,000 residents, typically with complex health care needs. Johns Hopkins HealthCare was a close partner in this effort.

J-CHiP included both community- and acute care-based interventions to improve health. The community-based component targeted local Medicare and Medicaid residents with average annual health care costs totaling between $30,000 to over $55,000 prior to enrollment. Among this population, 69 percent had six or more chronic conditions, at least 32 percent had depression or another mental health condition, and 45 percent of the Medicaid patients had substance use disorders.

Each patient enrolled was assigned to a team that included a primary care provider, clinic-embedded case manager and community health worker. Some also had a health behavior specialist or a neighborhood navigator. Initial patient contacts, often done in participants’ homes, noted barriers to care. J-CHiP provided low-cost bus tokens, cab or shuttle support to about 550 patients in need of transportation to medical appointments; a pharmacy assistance program to make medications more affordable for nearly 400 patients; and cellphones preprogrammed with provider phone numbers to 113 patients to keep them engaged.

Some of the program’s ambulatory efforts will be sustained through the Johns Hopkins Medicine Alliance for Patients, an accountable care organization, and much of the program components will continue through other hospital initiatives and the Community Health Partnership of Baltimore. Through this new initiative, supported by the Health Services Cost Review Commission, six Baltimore hospitals, including The Johns Hopkins Hospital and Johns Hopkins Bayview, will collaborate with Healthcare for the Homeless and continue to work with community organizations, such as Sisters Together and Reaching and the Men and Families Center, to improve care for high-risk Medicare and Medicaid patients in Baltimore.