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Spreading Innovations in Health Care Delivery

This website, endorsed by Maryland’s Stakeholder Innovation Group, offers a glimpse at how many of Maryland’s health care providers and community organizations are working together to improve care delivery.

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JHM - Behavioral Health Integration - Johns Hopkins Medicine Alliance for Patients (JMAP)

  • What are the objectives of the program?

    Improved care coordination

  • Please provide a brief description of the program:

    The Johns Hopkins Medicine Alliance for Patients (JMAP) is a Medicare Shared Savings Program Accountable Care Organization (ACO). A behavioral health team consisting of health behavioral specialists (who are clinical social workers) and psychiatrists are embedded in community-based primary care settings to provide behavioral health care to Medicare patients in several counties in Maryland. Health behavioral specialists provide mental health psychosocial assessment, counseling and links to community based mental health services. Psychiatrists provide patient assessment and consultation regarding pharmacotherapy and other types of treatment to primary care providers. Community health workers provide outreach in person to patients as needed to help with decreasing barriers related to social determinants of health.

  • Is this program operated as part of HSCRC's Care Redesign Amendment?


  • What are the major components of the program?

    Care coordination/management, Patient education/coaching/self-management, Multidisciplinary care teams, Patient care plans, Community health workers, Interventions to address social determinants of health, Risk stratification

  • What types of organizations participate in the program?

    Physicians office (primary care), Behavioral health provider (e.g., mental health and/or substance abuse)

  • Which population(s) does the program target?

    Medicare/older adults, Individuals with multiple chronic conditions

  • How many patients have participated in the program to date?


  • In what Maryland jurisdictions do participating patients reside?

    Allegany, Anne Arundel, Baltimore, Baltimore City, Calvert, Carroll, Charles, Frederick, Harford, Howard, Montgomery, Prince Georges, Saint Marys

  • Briefly describe the staffing resources required to operate the program:

    Over 30 primary care clinics are in the ACO. The staffing ratio for the program is roughly 1:100 and is structured as a combination of embedded and telephonic support. For example, an embedded clinic may have one clinical social worker who works full-time, but can also support additional practices on a consultation basis. One psychiatrist provides clinical services in person one full day a month. The psychiatrist provides informal consultation to primary care providers in person, by telephone and EMR. The psychiatrist also provides mental health support and consultation to the clinical social worker by telephone one hour a week. A community health worker is designated to a region that services various primary care clinics to work with patients on an as needed basis.

  • Briefly describe the key initial steps to implementation:

    Key initial steps included: 1) definition of the embedded model and interventions, 2) determination of embedded primary care sites and stakeholder buy-in, 3) development of EMR tools and reporting mechanisms, 4) definition of regional model consisting of primary sites who receive telephonic services from teams at embedded sites, 5) development of program evaluation measures.

  • Are incentive payments to health care providers part of the program?


  • What are/were the expected results in improved outcomes, population health, and cost savings?

    The goal of the program was behavioral health integration. We collected process outcomes such as number of patients served. We do have clinical outcomes measures and are in the process of developing a way to determine how to assess patient health outcomes, eg. depression and anxiety systematically.

  • Have expected results for improving outcomes and population health been met?

    Some of the expected results were achieved

  • Please briefly explain your answer to Question 25, and describe any results for improved population health achieved to date:

    Analysis of results are in progress., Some of the expected results were achieved

  • Please briefly explain your answer to Question 27, and describe any cost savings results achieved to date:


  • Please provide URLs to any published evidence (e.g., peer-reviewed literature, white papers, etc.)