Speaker 1: 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 was able to improve the perceived satisfaction by patients of the care they're providing. And also, it showed a reduction in readmissions due specifically to congestive heart failure. There's been an inpatient 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.

Speaker 2: 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.

Speaker 1: 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 costs.

Speaker 2: Before the Community Health Partnership arose, on the acute care side, we recognized that we needed to be doing a better job in having a more concerted effort toward 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 inpatient 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 a 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 who discharge those patients so that we can learn from our

Speaker 1: own readmissions. The new Community Health Partnership is funded through a CMS grant. It's 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 health care professionals that will be a link between patients and the health care system, and they'll 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 a day? That's a quarter. Once a day. It should be twice a day. I'll try 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 in their neighborhoods have been doing, but they're going to also be a bridge to the health care system so that we can try and bring resources needed to patients directly into their neighborhood. Giving them access to resources to improve their health, to change behavior so that they may be able to do things like stop smoking where they haven't been able to before, that will be able to prevent those unnecessary hospitalizations, and therefore save money by avoiding that type of spending. And the idea also is to improve health, so if you're healthier, you don't need to use health care resources.

Speaker 2: 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.