Organization: Johns Hopkins Bayview Medical Center, Community Psychiatry Program 

Innovation Types: Comprehensive Case Management

What They’re Doing: Team based comprehensive case management for high-risk psychiatric patients.

Clinical Innovation: Multi-disciplinary teams consisting of psychiatry, nursing, social work and case managers provide preventive care and management for the mental, behavioral and somatic health needs of high risk psychiatric patients in community settings. Once enrolled in the program, each member receives a person centered plan and is connected with a staff member who offers care coordination, health education, support for lifestyle changes, respite care, crisis services, inpatient hospital support and guidance on adherence to the plan and assists the member in accessing non-health care services that are related to health status such as adequate housing, adult day care, transportation. The program also helps members access entitlements, substance abuse services, somatic care and employment support. Staff is available to members 24 hours a day.

Supportive Financing Mechanism: Per Member Per Month Fee. Receives a $2,410 per member per month fee from Value Options, Maryland’s provider of mental health coverage to individuals with medical assistance to provide all mental health/psychiatric services for members enrolled in the program. The program is responsible for paying for the member’s regular psychiatric treatment, therapy, medications and case management as well as any supportive care. In addition to usual care, the program is responsible for paying for all psychiatrically-related ED visits and hospitalizations. The program is not responsible for somatic care if the individual has insurance.

Evaluation Type: Non-Experimental/ Qualitative Support

Evaluation Plan: Creative Alternatives (CA) has had ongoing evaluation since inception through an annual report card mechanism.   An independent organization evaluates the CA program. CA is graded on positive outcomes and negative outcomes.   Positive outcomes include improved wellbeing, employment and negative outcomes include days on the street (homeless), days hospitalized, maintenance of housing, community integration, meeting goals on the person-centered plan, linkage with somatic care and connection to family.

Patient Health Cost Outcomes: The program has been successful at keeping high risk psychiatric patients stable in community settings for long periods of time.  It has become rare for anyone to be hospitalized; it is unusual for more than one person in the whole program to be in the hospital at any given time.

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Publications: None

Target Population: high users of high cost psychiatric services, primarily patients with long term state hospitalizations or recurrent inpatient psychiatric admissions.  186 patients are enrolled in the program.

Date of Implementation: 1994  

Contact:   Sheila Goldscheider   at 410-631-6148 or sgoldsc1@jhmi.edu  or Dr. Anita Everett at aeveret4@jhmi.edu

Multimedia: Pending

Where to learn more: Please contact Sheila Goldscheider.