When Maryland’s Health Services Cost Review Commission put out a call for regional partnerships to improve population health and decrease hospital readmissions among high-user Medicare recipients, Johns Hopkins Medicine jumped at the opportunity. Now, four of the health system’s hospitals are active in three of eight statewide partnerships working to provide better care to these patients. They are the Community Health Partnership in Baltimore, Howard Health Partnership and Nexus Montgomery Regional Partnership.
“What we’re finding is these patients are not well-connected to a medical home, so many of them are using the emergency department and the hospital as their primary source of care,” says Linda Dunbar, vice president of population health for Johns Hopkins HealthCare. So the partnerships aim to connect patients who have three or more hospital admissions to a regular health care provider, work out treatment plans and help with social determinants of health, such as barriers to transportation and healthy food, or finding affordable housing, Dunbar says.
Community Health Partnership is coordinated by Johns Hopkins HealthCare and comprises The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, as well as Sinai Hospital, Mercy Medical Center and two MedStar hospitals. Working with community health partners, Community Health Partnership serves residents in 19 ZIP codes surrounding East Baltimore, with about 200 of a planned 1,300 patients enrolled. Its network of community care teams and workers reaches out to patients for initial health assessments and creates care plans. Additional efforts are medical visits for homebound seniors, transitional housing for the homeless and a bridge to community-based mental health services.
“Some of the individuals we contact have as many as six or seven chronic comorbid conditions, mental health diagnoses and substance use diagnoses, so it’s a very complex picture that we’re seeing,” says Dunbar.
Leaders at Howard County General Hospital study their inpatient list every morning, looking for eligible adults for the Howard Health Partnership, says Elizabeth Edsall Kromm, vice president of population health and advancement. They want to make patients feel like they’re active participants in their health care, says Edsall Kromm.
A multidisciplinary community care team provides one to three months of help offering home care visits, accompanying patients to primary or specialty care appointments, and connecting patients to resources for any socioeconomic needs. Other initiatives smooth transitions to home or a postacute care unit, offer disease management classes and caregiver help, and supply rapid access to behavioral health care. More than 500 people have been touched by this partnership since it started in July 2016.
A third partnership, based in Montgomery County, includes Suburban Hospital, along with five non-Johns Hopkins Medicine medical centers. The Nexus Montgomery Regional Partnership’s programs include WISH (Wellness and Independence for Seniors at Home), which provides case management to some 7,000 seniors in 42 independent-living facilities found to have high hospital use. Other efforts furnish funds for a crisis house for patients with severe mental illness and help get uninsured patients access to specialty care.
The best part, says Margie Hackett, a transition guide nurse manager at Suburban, is how the partnership allows better care coordination for patients who might be seen at multiple facilities: “This collaboration between facilities is like none other.”
