2

JH US Family Health Plan

• 1981: US Public Health Service Hospitals 

designated to provide health care for uniformed 

services beneficiaries 

• 1993: USTFs mandated to provide services 

through a fully at-risk managed health care plan 

• 1996: Congress designates that the USTFs 

provide the TRICARE Prime benefit as 

“TRICARE Designated Providers” making them 

a permanent component of the MHS

• 1998: USFHP implements the TRICARE Prime 

benefit
USFHP Alliance

3
4

US Family Health Plan

• Fiscal Year 1997 National Defense Authorization Act “The health care delivery 

system of the uniformed services shall include the designated providers.” 

TRICARE

TRICARE 

Standard (FFS)

TRICARE Extra 

(Preferred 

Provider)

TRICARE Prime 

(Managed Care)

US Family 

Health Plan

Military 

Treatment 

Facilities & 

MCSC

TRICARE For 

Life (65+ 

Medicare 

Supplement)
JH Enrollment

5

Active Duty Family/Members 11,119

 

<65 Retirees 20,799

65+ Retirees 8,279

Total 40,197 
JH Privileged to Serve Since 1981... 

6
7

Johns Hopkins USFHP Network

7
JH US Family Health Plan Quadruple Aim
2012 Accreditation 

Scoring

JH USFHP 

Points

Possible 

Points

Standards 53.0752 54.14

HEDIS Effectiveness of 

Care Measures Score

28.6025 32.86

CAHPS Measures 

Score

13.0000 13.00

Total & Status Level 94.6777

Excellent

100.00

JH Member Health & Experience

9
Overall Satisfaction 

Source: 2012 The Myers Group Survey and 2012 Public Report benchmark derived from NCQA 

Quality Compass Public Report and calculated by The Myers Group.

Comparison to national averages for member satisfaction with non-PPO plans (all percentages = 

proportion highly satisfied, rating plan 8 through 10 on a scale from 0 to 10, where 10 is the best 

possible plan). 2006–2012 surveys conducted by NCQA Certified vendor.

USFHP Alliance Member Experience 

Among the Highest in America 
POPULATION HEALTH .

AND THE TECHNOLOGY TO 

SUPPORT IT
Johns Hopkins Medicine and 

Accountable Care

Johns Hopkins Medicine has all the necessary components to 

achieve a high-performance integrated delivery system.

Home Care

Primary Care Specialty Care

Hospital Care

USFHP the 

payer:

40,000+ 

members of our 

health plan

12
A Model for an Accountable Care System:

Provider and Member Engagement

USFHP as 

Payer 

Providers Members 

Member 

Outcomes 

Collaboration 

Motivation and engagement 

that facilitates selfmanagement of condition 

Evidence-based 

outcomes based on 

conditions 

 

Adherence to evidence 

based, guideline 

driven care 

13
Achieving the Quadruple Aim:

A Population Health Approach

Identify and target beneficiaries in need of services

Assess Needs and Goals of beneficiary

Develop Patient Centered Action Plan 

Intervene and carry out Action Plan with Patient
How do we identify and target 

those in need of services?

15
Variables in the Predictive Model

Hospitalization 

in 2011

ACG Risk 

Score

Co-morbid 

Conditions:

Elevated lab values

Diabetes complications

Hyperlipidemia

CAD

HF

Renal

COPD

Asthma

Depression

Substance Use

Enrollment 

lapse

Any

# of lapses

Demographic

Age

Sex

Zip Code

Region

JHHC Line of Business

Total 

Costs Utilization

Primary

Specialty

Hospital Admits Pharmacy:

Total Count

Use of insulin

Use of Insulin Pen

Lack of claims for supplies

Claims for Glucagon

Untreated diabetes

PPI use

16
The ACG Predictive Model

• What the ACG-PM does:

– Grounded in the disease burden or co-morbidity 

perspective unique to the ACG system

• Focuses on commonly occurring patterns of morbidity and 

assessment of all types of medical needs

• Holistic method has repeatedly proved to have many 

advantages over comparable case-mix approaches that 

include limited a set of diseases or episode categories.

– Builds on facets of the ACG system and several years 

of intensive research and development at JHU

– Uses statistical techniques to project the impact of 

co-morbidity and other factors on an individual’s 

use of health care resources in a future time period

17
ACG-PM Outputs

• ACG-PM produces two types of predictive 

risk indicators:

– Probability Score: represents the likelihood 

that a member will be among those persons 

using extraordinary health care resources

• Scores range from 0 to 1. Score of 0.4 means the 

individual has a 40 out of 100 chance of being in 

the high-risk cohort next year

– Predicted Resource Index: can be readily 

converted to a predicted dollar amount

• Scores range from 0 to roughly 40 with a population 

mean of 1.0. 18
USFHP Population we serve

Characteristics of high-risk group: 

• 46% have 1 or more hospital 

admissions in 2012

Characteristics of low and moderate 

risk Group:

• 16% have one admission

65% of all admissions are accounted 

for by the high risk group

High

Complexity

>=0.4

probability of IP

admissions

Moderate and Low 

Complexity

<0.4 probability of IP 

admission

19
Achieving the Triple Aim:

A Population Health Approach

Identify and target members in need of services

Assess Needs and Goals of members

Develop Patient Centered Action Plan 

Intervene and carry out Action Plan with Patient
Case Management and Behavioral 

Assessment Completed in Database

ͻ Health status

ͻ Medication Adherence

ͻ Life-planning Activities

ͻ Cultural and Linguistic 

needs, preferences and 

limitations

ͻ ADLs

ͻ Caregiver resources

ͻ Nutrition

ͻ Physical Activity

ͻ Pain

ͻ Stress

ͻ Sleep 

ͻ Tobacco Use

ͻ Alcohol Use

ͻ Substance Use

ͻ Emotional Status and 

Depression

ͻ Domestic violence and 

neglect

ͻ Cognitive Function

ͻ Patient Activation
The Assessment of Needs

More comprehensive for high-risk patients

~150 questions for high risk patients

~50-60 questions for medium risk

About 20-30 mins. 

Multiple assessment methods available, based on patient 

preference and need/usability

Mailed, web-based, face-to-face interview in clinic, faceto-face interview in home conducted 

Data scanned/direct entered into centralized USFHP 

database

Achieved high response rates from USFHP members

22
Sample Assessment Questions

68% of the US population 

reads at a Basic or Below 

level. The literature shows 

direct associations between 

low literacy and poorer 

health outcomes.

23
Care Management System Produces Summary of 

Assessment 
Achieving the Quadruple Aim:

A Population Health Approach

Identify and target beneficiaries in need of services

Assess Needs and Goals of beneficiary

Develop Patient Centered Action Plan 

Intervene and carry out Action Plan with Patient
Individualized Patient-Centered Care:

Specific behavioral and social interventions 

Individualized intervention plan triggered by assessments, targeting specific 

behavior needs

Each assessment domain has recommended interventions for follow-up

Meet 2012 NCQA standard for evidence-based tools and approaches to 

patient counseling and intervention

Disease-specific 

Self-Care Behavior 

Needs

Health Behavior Risk 

Needs

Case Management 

Needs

•Care Coordination

•Case Management

•Assistive/Support 

Interventions

•Social and 

Economic Needs

•Counseling

•Lifestyle modification coaching

•Smoking cessation 

•Weight management

•Specialist referrals (addiction, 

major depression, cardiac rehab, 

neuro/early dementia)

•Behavior change 

counseling

•Health Coaching

•Family Training

•Social and instrumental 

support 26
– The primary objective of the Interdisciplinary Team (IDT) 

will be to establish an Initial Care Plan and to monitor the 

progress of the JCHiP patients against the plan of care. 

– IDT schedule. The Case Manager will create a schedule of 

patients who will be discussed at the IDT meeting. The 

schedule will be organized around the Case Manager/CHW 

pair and grouped by Primary Care Provider when possible. 

The schedule will be posted in the JCHiP software and 

communicated to all team members.

Care Plan
Achieving the Quadruple Aim:

A Population Health Approach

Identify and target beneficiaries in need of services

Assess Needs and Goals of beneficiary

Develop Patient Centered Action Plan 

Intervene and carry out Action Plan with Patient
USFHP Medication Adherence: 

Intervention to Address Needs

Table. Factors Impacting Care Delivery and Adherence to Care

FACTOR DATA 

SOURCE STRATEGY MODALITY

Patients’ Capacity

Lack of clear education re: medical conditions

Case studies

EBMC experience

Literature

Care coordination

Education

Simplify treatment

Build capacity

CCC becomes a point 

of contact

NCM, CCC

Incomplete understanding of severity of condition or consequences of non-compliance

Lack of knowledge about health and social service systems

Health literacy

Difficulty discerning when to seek care or professional health advice

Inability to navigate health and social service systems

Difficulty overcoming barriers without assistance

Treatment complexity

Patients’ Attitudes/Beliefs

Belief that medical care is not important

Case studies

EBMC experience

ICHABOD

Informal counseling & 

social support

Organize health buddies

NCM, CCC

Unwillingness to face severity of health condition

Mistrust of health system

Fear of medical procedures and side effects

Lack of confidence that patient’s actions can improve health

Social and Economic Environment

Transportation

Case studies

EBMC experience

Care coordination

Social stabilization CCC

Unstable and/or unsuitable housing

Finance and resource insufficiency

Lack of social support for healthy behaviors

Household members’ engagement in behaviors harmful to patient

Health System

Patient-provider communication

Case studies

EBMC experience Care coordination NCM + CCC

Inefficiencies in processes

Complexity of referral processes

Inadequate follow-up or discharge planning

Cost of medication, copayment, or both 29
Integrated, Team-based

Primary Care

Integrated Primary Care combines 

medical and behavioral health services 

to more fully address the spectrum of 

problems that patients bring to 

primary medical care.

- Integrate a new discipline – Behavioral Team – into the 

Primary Care Team

- Community based health workers extending services 

into the patients home and neighborhood

- Lift some burden from the primary care team

- Adjust the workflow
What Do Successful PCMH

Interventions Have in Common? 

• Target high risk patients

• Strong transitional care

• Medication management

• Ongoing assessments and monitoring of patients 

with chronic conditions

• Focused, streamlined care plans

• Close communication between care managers, 

patients, primary care doctors, and specialists

• Personal face to face contact between care 

coordinator and patient
Clinic Based Team: Behavioral Specialist, 

Case Manager, and Primary Care Physician

Nurse Case Managers embedded in primary care 

clinics are responsible for

– Initial Assessment and Survey

– Ongoing Self-management support

– Develops and Communicates Care Plan with 

member and clinic team
Clinic Based Team: Behavioral Specialist, 

Case Manager, and Primary Care Physician

Primary Care Physician leads each team

– Oversees the care

– Has electronic and periodic in-person 

interactions with the care team

– Regular appointments with each patient
The Interdisciplinary Team Process
In Summary ..

Population Health Approach

• Technology to support our approach

– Data architecture to join multiple data sources at a patientcentric level (claims, EMR, pharmacy, self-reported surveys 

and symptoms)

– Predictive models (sophisticated biostatistics software)

– Systems that support collection of data that leads to 

summaries of needs/problems, creates care plan, tracks 

interventions and coordination amongst team members

– Outcomes and data reporting (intelligence and decision 

support)

– Portal for patients and caregivers (view, write to medical 

records, communicate with care team)
DISCUSSION, Q&A