Association of a Care Coordination Model With Health Care Costs and Utilization

Medicare and Medicaid participants in East Baltimore, Maryland. Community intervention (CI) group: 2,154 Medicare beneficiaries (mean age 69.3, 61.3% female) and 2,532 Medicaid beneficiaries (mean age 55.1, 67.3% female). Acute care intervention (ACI) group: 26,144 beneficiary-episodes for Medicare (mean age 68.4, 52.5% female) and 13,921 beneficiary-episodes for Medicaid (mean age 52.2, 53.1% female).

Johns Hopkins Community Health Partnership (J-CHiP) care coordination model, consisting of an acute care intervention (ACI) bundle for transition planning following discharge and a community intervention (CI) for enhanced care coordination and integrated behavioral support.

Propensity score-weighted preintervention group at J-CHiP hospitals and concurrent comparison group from similar Maryland hospitals (for ACI); propensity score-matched comparison group of local residents (for CI).

Utilization measures (hospital admissions, 30-day readmissions, and emergency department visits), quality of care measures (potentially avoidable hospitalizations, practitioner follow-up visits), and total cost of care (TCOC).