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
(Click image for larger view and slideshow.)

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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25 Years Of Health IT: A Complicated Journey
25 Years Of Health IT:
A Complicated Journey
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field assessments done on a tablet in the patient's home. "We are still working on the mapping technology so we can fully schedule the care workers," said Corkran.

Now, back to those challenges. First, the technology: Corkran said that when she first suggested Salesforce as the platform, none of the organization's stakeholders knew what it was. Further, none of them had ever heard of CRM. It took some education to help them understand what the technology could do.

There was a great deal of concern about potential risks in exposing personal health information to a cloud-based SaaS platform, according to Corkran. She noted that the organization's chief security officer was familiar with the technology, which helped alleviate these concerns. "When I took it to our chief security officer, his response was, 'Oh, Salesforce, that's no problem.' "

When it comes to calculating ROI on care coordination, it's worth looking at the national statistics that Corkran shared:

  • 1% of the US population accounts for 22% of healthcare spending.
  • In Medicaid programs, 5% of patients account for 54% of spending.
  • Patients in this 1% typically have three or more chronic conditions, such as HIV, diabetes, and congestive heart failure.

"It's not rocket science to understand, if you need to reduce healthcare costs, where you really need to focus your attention," said Corkran. Yet, she added, quantifying ROI in this type of program is extremely challenging. "It's very hard to quantify care that doesn't happen. If the program is highly successful, these people don't show up at the ER, they monitor their blood sugar, they stop smoking. That's a good thing, but makes it difficult to calculate ROI."

Anecdotally, she said, engaging the patient and a care team with each other does the following:

  • Increases patient satisfaction
  • Improves the management of diseases
  • Improves pain management
  • Increases quality of life
  • Decreases depression
  • Optimizes cost and decreases utilization
  • Decreases hospitalizations
  • Decreases ER visits
  • Decreases hospital stays

What's next for Corkran and the organization's care coordinators? In 2013, they participated in a two-day session as part of Salesforce's Ignite program. "We created a vision: What could care coordination look like in the future, with a complete system of record -- your [electronic medical records] system -- and a mobile system of engagement?" The team also looked at how social networking could be used to mobilize community volunteers to get involved in the care of their neighbors.

"Our journey continues," said Corkran. "We're not 100% sure where it will end. Our hope is that we can equalize the disparity of life expectancy within a mile outside our windows."

The owners of electronic health records aren't necessarily the patients. How much control should they have? Get the new Who Owns Patient Data? issue of InformationWeek Healthcare today.

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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