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Case Study: Johns Hopkins Community Health Partnership: A model for transformation

机译：案例研究：约翰霍普金斯社区健康伙伴关系：转型模型

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To address the challenging health care needs of the population served by an urban academic medical center, we developed the Johns Hopkins Community Health Partnership (J-CHiP), a novel care coordination program that provides services in homes, community clinics, acute care hospitals, emergency departments, and skilled nursing facilities. This case study describes a comprehensive program that includes: a community-based intervention using multidisciplinary care teams that work closely with the patient's primary care provider; an acute care intervention bundle with collaborative team-based care; and a skilled nursing facility intervention emphasizing standardized transitions and targeted use of care pathways. The program seeks to improve clinical care within and across settings, to address the non-clinical determinants of health, and to ultimately improve healthcare utilization and costs. The case study introduces: a) main program features including rationale, goals, intervention design, and partnership development; b) illness burden and social barriers of the population contributing to care challenges and opportunities; and c) lessons learned with steps that have been taken to engage both patients and providers more actively in the care model. Urban health systems, including academic medical centers, must continue to innovate in care delivery through programs like J-CHiP to meet the needs of their patients and communities.
机译：为了解决城市学术医疗中心服务人群的挑战性医疗需求，我们开发了约翰·霍普金斯社区健康伙伴关系（J-CHiP），这是一个新型的护理协调计划，在家庭、社区诊所、急症医院、急诊科和熟练护理设施提供服务。本案例研究描述了一个全面的项目，包括：社区干预，使用多学科护理团队，与患者的初级护理提供者密切合作；急性护理干预包与基于团队的协作护理；以及强调标准化过渡和有针对性地使用护理路径的熟练护理设施干预。该项目旨在改善医疗机构内部和外部的临床护理，解决健康的非临床决定因素，并最终提高医疗利用率和成本。案例研究介绍：a）主要项目特征，包括基本原理、目标、干预设计和伙伴关系发展；b） 人口的疾病负担和社会障碍导致护理挑战和机遇；以及c）通过采取措施让患者和提供者更积极地参与护理模式而获得的经验教训。城市卫生系统，包括学术医疗中心，必须通过J-CHiP等项目继续创新医疗服务，以满足患者和社区的需求。

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