How We Work to Achieve Our Goals: Pillar Alignment Model

Multidisciplinary Care Coordination Team

The Clinical Services Team seeks to optimize the cross-functional care model across the continuum of care. Team members work in primary care clinics that participate in the Johns Hopkins Medicine Alliance for Patients Care Transformation Organization. Clinical services include integrated behavioral health treatment, ambulatory pharmacy services and care management. Team members also support patients with education about and connection to resources, address individual clinical and social determinants of health concerns, and promote wellness, self-care management and cost-effective outcomes.

Community Health Workers (CHWs), are nonclinical staff members who possess a unique knowledge and understanding of the community they serve. The CHW is a link between health care services and the community, facilitating access to resources to improve the quality and cultural competence of service delivery.

CHWs focus on building relationships and trust while working to address the social determinants of health that impact our patients’ ability to maintain and improve their health and well-being. CHWs work closely with and are an integral part of the care teams. CHWs conduct home visits and engage in community events.

Administrative Services Team

The program administration team is responsible for operational management of the care transformation organization. The team provides project management services to promote value-based care, quality of care and process improvement. Additionally, it serves as the primary point of contact for population health programs and facilitates collaboration between providers, practices and entity hospitals.

Analytics and Evaluation Team

The JHM Office of Population Health Analytics (OPHA) is constructed to advance enterprise-wide population health management (PHM) strategic pillars, principally via continuous evaluation of population-based performance measurement analytics, including process and outcome metrics.

An OPHA evaluation portfolio will assess the trended performance of a comprehensive measure set of short to intermediate, and long-term outcomes, attributable to enterprise-wide populations of interest. In doing so, OPHA will prioritize the quantification of an impactability-based framework designed for optimal deployment of PHM interdisciplinary care team resources (i.e., care management, behavioral health, pharmacy and community health workers) and evidence-based/informed PHM models of care.