Johns Hopkins Community Health Partnership: Transforming Patient Care Through Collaboration (Full Transcript)

Speaker 1: Big ideas thrill us. They can change the way we see things. Sometimes they change the world. And what appears to be one person's bright idea, more often than not, was a team effort. And just like cars need roads, and gas stations, and mechanics, great ideas need a network. The Johns Hopkins Community Health Partnership is a big idea. An idea built on ideals, people, communities, partnership. We created a network of providers, coordinators, community physicians, and partners to improve patient care and outcomes to keep our community well. And if patients do end up in the hospital, to help them get healthy and stay healthy so they don't return to the hospital in crisis. There are a lot of factors that impact our health. Our understanding of our illness and how to manage it, the level of communication between our providers, how the results of our tests are shared, and what happens to us after a hospital stay. With a grant from the Centers for Medicare and Medicaid Services, the Johns Hopkins Community Health Partnership was formed to build systems to support patients throughout the continuum of care. New workflows, bringing people together from the start. New technologies for sharing medical information between providers, and with the patient too. And new staff positions like community health workers, neighborhood navigators, and transition guides who give one-on-one support upon discharge, like optional home visits, coordinating appointments and community services, following up on medications and testing, and concentrated support from health behavior specialists, because change is never easy. The enhanced services focus on the patients in our community who need our help the most. Tens of thousands per year, mostly in the neighborhoods around our East Baltimore campus and Johns Hopkins Bayview. Patients who wrestle with chronic illnesses and social challenges that are at high risk of relapse. The Johns Hopkins Community Health Partnership aims to provide better access, education, and follow-up care so that patients become powerful forces in their own health care. The way it works is through a network of solid relationships, providing the care the patient needs, in the right place, at the right time. You know, some of the greatest ideas have been super simple, like the Johns Hopkins Community Health Partnership's plan to put patients at the center. Now that's a big idea.