Here's what we all know.
Too many people are getting sicker,
instead of better,
after they leave the hospital.
And what's crazy is... a lot of it is preventable.
There are things we can all do. Caregivers... patients... families...
The first step is to admit that it won't get better
if we keep doing the same thing.
Because that would be crazy.
At Johns Hopkins Medicine, we've been working at this for a while.
So it's interesting, the Community Health Partnership has really been in many
smaller ways things that Hopkins physicians and nurses and healthcare
professionals have been working on for years. For example the Aliki Initiative has been
able to improve the perceived satisfaction by patients of the care they're providing
and also it would show the reduction in readmissions due specifically to
congestive heart failure.
There's been an in-patient group working to reduce readmissions and they've been
able to successfully reduce readmissions in multiple pilot units at both Johns
Hopkins Hospital and Johns Hopkins Bayview.
If we are doing a good job at communicating, at coordinating care we'll
have less of a problem with patients needing unneeded care such as readmissions
to the hospital, such as emergency room visits. These are activities that are bad for
patients, demoralizing for their families,
and are wasting healthcare resources.
J-CHiP is intended to improve on that.
The goal of the Johns Hopkins Community Health Partnership is really to improve
the quality of care that we provide to our patients while maintaining and reducing
healthcare cost.
Before the Community Health Partnership arose on the acute care side we recognized
that we needed to be doing a better job and having a more concerted effort towards
communicating with patients and their families and outpatient providers about
the care of their patients.
So there have been a number of tools that we've developed that help to make sure
that outpatient providers are informed about the in-patient hospitalization,
electronic tools that help providers communicate even when they don't have
electronic records that are shared by Johns Hopkins.
We also have used technology to improve education of patients so we have
tablet-based education curricula that even people who have no computer literacy can
use because it's just a matter of pushing the button on the screen to hear about
important information about your disease or your new medications.
We've had efforts at identifying in real time when patients are being readmitted to
the hospital and alerting the providers to discharge those patients so that we can
learn from our own readmissions.
The new Community Health Partnership is funded through a CMS grant, one of the
largest grants given at almost $20 million and that's going to allow us really to
invest in the infrastructure that can help bring many of those people together that
had been working to improve health before and it's going to really allow us to do it
on a scale that we've never seen before at Hopkins.
One of the most innovative aspects is our transition guides.
Transition guides are healthcare professionals that will be a link between
patients in the healthcare system and are going to really be based in the community
and outside of the hospital.
I'm confused. I understand because you have a lot.
How many times do you take this one today?
Once a day. It should be twice a day.
I was trying to stretch it out. It's expensive.
Another group we're recruiting and hiring for are community health workers
and they're really people that are integrated already into the neighborhoods that are
part of the local community that are more aligned with what our patients and their
neighborhoods have been doing but they're going to also be a bridge to the
healthcare system so that we can try and bring resources needed to patients
directly into their neighborhood,
giving them an access to resources to improve their health, to change behaviors so that
they may be able to do things like stop smoking where they haven't been able to
before, that we'll be able to prevent those unnecessary hospitalizations
and therefore save money by avoiding that type of spending.
The idea also is to improve health so if you're healthier you don't need to use
healthcare resources.
The Community Health Partnership we hope will be a model for other academic medical
centers to follow. If we're able to fully implement J-CHiP
in a way that is providing us the data we need to create generalizable knowledge.
We are excited that we'll be able to show the nation how care can be coordinated in
a way that can help patients from all walks of life.