RESUMEN
Johns Hopkins Medicine underwent a significant evolution with a new Office of Population Health (OPH), inclusive of a hybrid clinical and administrative structure, to optimally align expertise with care delivery functions. Initial priorities included identification of high-risk patients to receive care management, integrated behavioral health, and wraparound supports to address social determinants of health. A cross-functional care team provides multidisciplinary support for primary care practice patient needs, and efforts through the Baltimore Metropolitan Diabetes Regional Partnership have helped accelerate scaling of evidence-based diabetes prevention and management programs across the state. Through a multistakeholder process, OPH and partners developed a 3-year strategic plan, with guiding stars of reducing avoidable utilization and disparities in care. The plan prioritized (1) generation of a data and analytics road map, (2) advanced population management clinical services for priority populations, (3) improved performance on value-based care programming, and (4) enhanced health system coordination. With a new OPH, Johns Hopkins Medicine is better positioned to execute on value-based initiatives in support of its patients.
