The authors of a four-year Johns Hopkins project designed to both improve health in East Baltimore and save government dollars published their results today in the Journal of the American Medical Association (JAMA) Network Open.

The project, a pilot program funded by a $20 million Health Care Innovation Award from the federal Centers for Medicare & Medicaid Services, aimed to reduce barriers to care for underserved people in East Baltimore neighborhoods, as well as reduce hospital readmissions for many adult patients who came to The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center seeking care for acute health problems.

Designed by a team of physicians, researchers, nurses and administrators and health policy experts from Johns Hopkins University, the Johns Hopkins Health System and community partners, the Johns Hopkins Community Health Partnership, or J-CHiP, included acute care hospitals, ambulatory practices, local skilled nursing facilities and community-based organizations.

Scott Berkowitz, M.D., M.B.A., cardiologist and senior medical director for accountable care for Johns Hopkins Medicine, served as lead author on the JAMA publication, which reported a savings of $113 million to Medicare and Medicaid based on an independent program analysis performed by the nonpartisan and objective research organization NORC at the University of Chicago. Two other recent articles, in Medical Care and the Journal of Health Organization and Management, also reflect on the impact and learnings of the J-CHiP program.

“We set out to assemble a care-coordination model that could help keep people healthy and out of the hospital and to keep those already hospitalized from being readmitted,” says Berkowitz. “We believed we could also do it efficiently enough to improve care and at the same time save payers money. Our study suggests that this model of care coordination was associated with improved health outcomes and substantial cost reductions in an urban, academic health system.”

The first segments of the population that J-CHiP studied were the thousands of adult patients covered by Medicare or Medicaid who were hospitalized at The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center between 2012 and 2015. The goal was to make sure that patients being discharged were provided a coordinated plan to keep them from returning for the same problem. Resources such as follow-up phone calls from nurses, patient education materials and transition guide visits provided patients and their families or caregivers with encouragement and instructions for follow-up care.

While hospital readmissions were not reduced for the Medicare group in this segment of the study, the increased care coordination was associated with projected savings of $29.2 million over the three years of the inpatient pilot study. The study’s authors associate the savings with a reduction in skilled nursing facility-related expenses. 

Though the study segment’s Medicaid group was significantly smaller, the savings were twice as great, at nearly $60 million. This group also saw a dramatic decrease in emergency room visits that occured 90 days after hospitalization, reducing that number by 133 per 1,000 patients, or nearly 1,900 emergency visits.

Amy Deutschendorf, M.S., vice president for care coordination and clinical resource management for the Johns Hopkins Health System and a coauthor of the JAMA Network Open article, says,“It is likely that by assisting these patients with properly addressing their healthcare needs, visits to the emergency department were avoided.” 

The second of J-CHiP’s goals was to better coordinate care for people in East Baltimore who were identified as high-risk for hospitalization. In many of these neighborhoods, life expectancy falls as much as 20 years behind Baltimore’s wealthiest areas. The hallmarks of urban poverty are facts of life for thousands of residents of East Baltimore and eastern Baltimore County.

“Patients from these areas frequently suffer from mental health and substance abuse conditions,” says co-author Constantine Lyketsos, M.D., professor and chair of psychiatry at Johns Hopkins Bayview Medical Center. “We worked to establish an integrated behavioral health model in the interest of improving care for these patients.”

The J-CHiP program included a partnership between Johns Hopkins and two East Baltimore human-service nonprofit organizations, Sisters Together and Reaching (STAR) and the Men and Families Center. The nonprofits were vital to the project, supplying additional staff and expertise to provide outreach and support to neighborhood residents at high risk for hospitalization.

For the 2,500 Medicaid patients in this group, there was a $24 million savings for the government payer. The study’s authors associate care coordination with a reduction of 200 emergency room visits, almost 70 hospitalizations and nearly 80 readmissions within 30 days of original hospitalization.

“The association of the Medicaid intervention with improvements in key areas of utilization is notable and likely reflects our efforts to address the numerous barriers to patient care and our improved care coordination, says Raymond Zollinger, M.D., vice president of medical affairs at Johns Hopkins Community Physicians.

An important element of J-CHiP was the hiring and formation of care teams aimed at reducing barriers to care for underserved East Baltimoreans. In a paper published in July in the journal Medical Care, biostatistician Shannon Murphy, M.A., and several Johns Hopkins colleagues wrote that “addressing both clinical and nonclinical determinants of health is essential for improving population health outcomes.”

Murphy detailed the multidisciplinary teams assigned to high-risk Medicare and Medicaid beneficiaries, which included physicians, care managers, health behavioral specialists, community health workers and neighborhood navigators. Also key to success is engagement and collaboration with community-based organizations.

“J-CHiP’s multidisciplinary team approach to address clinical and nonclinical determinants of health appears to be a promising method for curbing rising healthcare costs, particularly for Medicaid patients,” says Murphy.

According to another journal article, published in August in the Journal of Health Organization and Management and authored by Johns Hopkins graduate researcher Ya Luan Hsiao M.D., M.P.H., one of the ways J-CHiP was unique was its focus on keeping low-income patients engaged in their care.

“Most care coordination interventions are focused on patients with a single disease or on one aspect of the impact to health,” says Hsiao. “But J-CHiP focused on the patients’ physical, social and mental health needs.” 

Patricia Brown, senior vice president of managed care and population health for Johns Hopkins Medicine and president of Johns Hopkins HealthCare, a managed care and population health organization owned by the Johns Hopkins Health System and the Johns Hopkins University School of Medicine, is a co-author of the JAMA article.

“More efficient and less expensive care were among the many encouraging results that came from the J-CHiP study,” Brown says. “We learned a great deal from this program and we’ve already incorporated many aspects of the pilot program into the work we deliver with our community partners.”

Authors of the JAMA Network Open article are Scott Berkowitz, M.D., M.B.A.; Shriram Parashuram, Ph.D., M.P.H.; Kathy Rowan, Ph.D., M.P.H.; Lindsay Andon, M.S.P.H.; Eric Bass, M.D., M.P.H.; Michele Bellantoni, M.D.; Daniel Brotman, M.D.; Amy Deutschendorf, M.S., R.N.; Linda Dunbar, Ph.D., R.N., PhD; Samuel Durso, M.D., M.B.A.; Anita Everett, M.D.; Katherine Giuriceo, Ph.D.; Lindsay Hebert, M.S.P.H.; Debra Hickman, M.Div.; Douglas Hough, Ph.D.; Eric Howell, M.D.; Xuan Huang, M.P.H.; Diane Lepley, M.S.N., R.N., MSN; Curtis Leung, M.P.H.; Yanyan Lu, M.S.; Constantine Lyketsos, M.D.; Shannon Murphy, Ph.D., M.A.; Tracy Novak, M.H.S.; Leon Purnell, M.Ed.; Carol Sylvester, M.S., R.N.; Albert Wu, M.D., M.P.H.; Ray Zollinger, M.D.; Kevin Koenig, M.P.P.; Roy Ahn, Sc.D., M.P.H.; Paul Rothman, M.D.;  and Patricia Brown, J.D.

The J-CHiP program was supported by the US Department of Health and Human Services, Centers for Medicare & Medicaid Services.

Giuriceo is an employee of the Centers for Medicare & Medicaid Services. Howell reports grants and personal fees from the Society of Hospital Medicine, grants from The John A. Hartford Foundation and personal fees from The Johns Hopkins University outside the submitted work. Rothman is a member of the board of directors of Merck. No other disclosures were reported.