Overcoming Health Disparities Is Goal of Baltimore Experiment

Community mental health care will be deeply affected as the Affordable Care Act continues to be rolled out, since an underserved, previously uninsured population will gain Medicaid coverage and present for treatment. The Center for Medicare and Medicaid Innovation (CMMI) is funding several experimental designs to improve health care and lower costs by testing new ways to cover these patients’ health care needs.

Johns Hopkins Medicine received a $19.9 million grant from CMMI for one of those experimental designs, said Anita Everett, M.D., a professor and director of community psychiatry at Hopkins, at the fourth annual Road to Recovery conference in Baltimore in September.

The Johns Hopkins Community Health Partnership—called “J-CHiP” for short—provides a range of services, concentrating on people with the greatest health care usage. Care is provided not only at the two large hospitals Hopkins operates, but also at numerous other practice sites in Baltimore.

The project looks at ways to overcome health disparities in the community among Hopkins patients, which can amount to a difference of 20 years of life expectancy between residents living in the Baltimore ZIP codes with the highest and lowest life expectancies.

Aaron Levin

“Most of those differences are due to treatable conditions,” said Everett, a member of the APA Board of Trustees.

Substance use disorders and psychiatric conditions such as depression, anxiety, and posttraumatic stress disorder are overrepresented in the J-CHiP’s high-risk target population, and they contribute to avoidable high costs and morbidity when not treated, she said.

J-CHiP relies on primary care physicians but also uses nurse care managers and about 75 locally recruited community health workers to follow up with patients and keep track of self-management, adherence to therapy, and barriers to care.

The program will cover about 15,000 acute-care patients, including 3,000 high-risk individuals, by the end of the three-year trial.

J-CHiP is divided into 11 protocols using a short-term design: an intake plus four follow-up sessions, which can be repeated if necessary. The initial screening is followed by assessments of specific problems, patient/family education about the condition, skills development, and goal setting.

“Initial assessments for these patients will be much broader than typical primary care evaluations,” said Everett. They will include a number of behavior factors such as nutrition, emotional status, sleep, substance use, domestic violence, cognitive function, and medication adherence.

For instance, if the screen identifies “stress” as a patient’s problem, the team discusses with the patient the elements of stress and helps establish at least one attainable, measurable behavioral (BAM) skill, like practicing breathing once a day. Patients agree to adhere to those home-practice assignments and record them in daily logs. Team members follow up for a minimum of three months using a mixture of clinic visits and phone calls.

The J-CHiP model hopes to bring a new workforce to bear on health behavior and psychiatric conditions in primary care, along with increased accountability for coordination. But breaking down silos is hard, even when they are “silos of excellence” at her institution, said Everett. The traditional workforce of primary care will be part of the new team approach, although they may need some additional training in techniques like improved interviewing skills.

Finally, said Everett, committed, dedicated team members will be essential. An experienced community psychiatrist on the team is crucial. “And a sharp and relentlessly organized project manager is worth her weight in gold,” she said. ■