How Johns Hopkins Delivers Coordinated Care - InformationWeek

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Healthcare // Clinical Information Systems
10:40 AM
Susan Nunziata
Susan Nunziata

How Johns Hopkins Delivers Coordinated Care

Johns Hopkins Community Health Partnership uses CRM to deliver a coordinated care model that engages an entire community for better health.

Mental Health Tools: From Office To Pocket
Mental Health Tools: From Office To Pocket
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There are two key challenges facing healthcare IT leaders who are looking to implement coordinated care. The first is educating physicians, clinicians, and other stakeholders about technologies, such as CRM, which are common in many industries but still relatively new in healthcare. The second is proving the return-on-investment of major care-coordination efforts, such as the Johns Hopkins Community Health Partnership.

Maryann Corkran, VP of information systems for Johns Hopkins Medicine, shared these challenges in her case study presentation Wednesday at Salesforce's Dreamforce 2014 conference in San Francisco.

We'll share Corkran's experiences with those challenges shortly. First, let's look at what the Johns Hopkins Community Health Partnership is all about. According to Corkran, the program was initiated by employees at Johns Hopkins Hospital in East Baltimore who were moved by the plight of residents right outside their windows, in one of the city's poorest neighborhoods.

The statistics are frightening. Residents in the most economically disadvantaged ZIP codes in Baltimore have a life expectancy 20 years shorter, on average, than those living in more affluent neighborhoods. "There's only a mile difference in proximity between these ZIP codes, and they all surround Johns Hopkins Medicine," said Corkran.

The challenges facing these residents are far more complex than simply addressing their immediate health needs. In fact, according to Corkran, getting people into care is only 20% of the equation for keeping them healthy; the other 80% is made up of psychosocial factors. Corkran broke down that 80% like so:

  • 40% is socioeconomic. This includes factors such as employment, education, income, support network, and community safety.
  • 30% is behavioral. Do they smoke? Do they have access to healthy food? What's their diet, and do they exercise? Do they use alcohol? Do they practice unsafe sex?
  • 10% is the physical environment in which they live. Access to healthy food is problematic. Parks aren't safe, which limits exercise options. Environmental issues, such as pollution, could exacerbate certain health conditions.

Corkran and her team quickly realized that an effective solution would require, not only a highly integrated team of medical professionals, but also organizations and individuals outside the hospital walls.

With a three-year grant from the US Centers for Medicare and Medicaid, Johns Hopkins initiated the Community Health Partnership, which includes healthcare teams made up of nurse educators, nurse transition guides, physicians, case managers, clinical pharmacy specialists, health behavior specialists, and community health workers, among others. Since the Community Health Partnership began in 2012, nearly 45,000 people have been enrolled, and more than 2,000 patients have a community health worker to help coordinate their care.

Community organizations participating in the program include the Baltimore Alliance for Careers in Healthcare, Baltimore Medical System, the Men and Families Center, Priority Partners, and Sisters Together and Reaching. In addition, five skilled nursing facilities in the area participate in the program.

"As part of this grant, we are walking into the neighborhood, meeting patients where they live," said Corkran. "It was important that we could carry assessment forms with us. It was also important that we could get data quickly into a medical record or to our care team to make decisions. We wanted to work with the patient to make plans for their care together, engaging them and their family. To do that we also needed to be able to map and schedule the care team throughout the neighborhood, so that supervisors could know where caregivers are at any given time."

The system uses Salesforce CRM, according to Corkran, with

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Susan Nunziata leads the site's content team and contributors to guide topics, direct strategies, and pursue new ideas, all in the interest of sharing practicable insights with our community.Nunziata was most recently Director of Editorial for, a UBM ... View Full Bio
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