A Targeted “Top 100” High-Risk Care Management Program Improves Adherence to Best Practices

From the 2018 HVPAA National Conference

Sarah Johnson Conway (Johns Hopkins School of Medicine and Johns Hopkins Medicine Alliance for Patients, LLC), Cassy Peterson (Johns Hopkins Health Care), Scott Feeser (Johns Hopkins Community Physicians and Johns Hopkins Medicine Alliance for Patients, LLC), Arielle Alvaro (Johns Hopkins Health Care), Linda Dunbar (Johns Hopkins Health Care), Lindsay Hebert (Johns Hopkins Health Care), Sarah Himmelrich (Office of Johns Hopkins Physicians), Sarah Kachur (Johns Hopkins Health Care), Regina Richardson (Johns Hopkins Health Care), Scott Berkowitz (Johns Hopkins School of Medicine and Johns Hopkins Medicine Alliance for Patients, LLC), Andrew Hughes (Johns Hopkins School of Medicine)


The Johns Hopkins Medicine Alliance for Patients (JMAP) is the accountable care organization (ACO) responsible for the quality, experience, and value of health care services provided to Medicare patients across the Johns Hopkins institutions and its community partners.


Care management programs have been successfully used by ACOs as one way to improve care coordination and value. Opportunities exist to expand and improve care management for the high-risk JMAP patient population, including increased enrollment and facilitating improved communication and collaboration among members of the care team. The goal of this effort was to expand care management services in high-risk JMAP beneficiaries to increase enrollment and reach targeted goals in 5 best practice areas: 1) In-person patient meetings (Target 90%); 2) Direct patient/physician interaction (90%); 3) Provide transitional care services (90%); 4) Educate patients (75%); 5) Provide medication review (90%).


A targeted high-risk care management program was developed to align with the best practice areas above. High risk patients were identified using the Johns Hopkins ACG® System predictive analytics model based on patient diagnosis and historical claims data. The 100 highest risk patients based on predicted likelihood of acute care utilization were identified and provided to the care management team for outreach each quarter. The care managers were engaged with an education series on best practices performance and documentation. A chart review process was utilized to assess enrollment and adherence to the best practices at baseline and at 3 and 6 months into the program.


At baseline 23% of the top 100 patients were enrolled in the care management program. At 3 months 29% were enrolled. The targeted high-risk program increased adherence across all 5 of the best practice areas, with increases as follows (baseline-6 months; target): 1) In-person patient meetings (57-75%; 90%); 2) Direct patient/physician interaction (35-95%; 90%); 3) Provide transitional care services (17-47%; 90%); 4) Educate patients (35-70%; 75%); 5) Provide medication review (17-40%; 90%). At 6 months into the program, adherence to the ‘direct patient/physician interaction’ metric reached the targeted goal of >90%.


A targeted care management program of high risk ACO patients was able to increase enrollment and adherence to care management best practices. While early in the program, at 6 months adherence to all best practice areas was improved, and 1 of the 5 had already reached the target level. Together with promotion of patient and caregiver engagement, optimizing the care management model will potentially result in improved quality of care and patient satisfaction and may reduce unnecessary utilization. Ongoing work aims to achieve further increases in enrollment and best practices adherence among the top 100, and to expand these efforts across the care management programs.

Implications for the Patient

The “Top 100” care management program increased adherence to best practices that have been shown to reduce unnecessary hospitalization. The program has potential impacts on care value directly in terms of decreasing cost, and through improving patient engagement and satisfaction.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog