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  • 1. Bending the Cost Curve and Improving Quality in One of America’s Poorest Cities Jeffrey Brenner, MD Executive Director/Medical Director
  • 2. Long-term Federal Debt !
  • 3. 7/20/12 3
  • 4. 7/20/12 4
  • 5. 7/20/12 6
  • 6. You are cordially invited to the first Camden City Healthcare Providers’ Breakfast History of CCHP"Join fellow clinicians to get acquainted, and to share strategies, resources, and ideas on providing health care to Camden City residents. ! Thursday, January 24, 2002 7:30 – 9:00 am At the Rutgers University Octagon Room, Camden Campus Center, North Third Street Sponsored by the Center for Strategic Urban Community Leadership at Rutgers University, Division of Urban Health in the Department of FamilyMedicine at Cooper Hospital, and the Camden Area Health Education Center Please RSVP to Daria Chacón at 856-963-2432 x218 by Friday, January 11.
  • 7. Camden Health Data!n  2002 – 2011 with Lourdes, Cooper, Virtua data! n  500,000+ records with 98,000 patients! n  50 % population use ER/hospital in one year!n  Leading ED/hospital utilizers citywide! n  324 visits in 5 years! n  113 visits in 1 year!n  Total revenue to hospitals for Camden residents $100 million per year! n  Most expensive patient $3.5 million! n  30% costs = 1% patients! n  80% costs = 13% patients! n  90% costs = 20% patients!
  • 8. Top 10 ER Diagnosis 2002-2007 (317,791 visits)!465.9 ACUTE UPPER RESPIRATORY 12,549 INFECTION (head cold) 382.9 OTITIS MEDIA NOS (ear infx) 7,638 079.99 VIRAL INFECTION NOS 7,577 462 ACUTE PHARYNGITIS (sore throat) 6,195 493.92 ASTHMA NOS W/ EXACER 5,393 558.9 NONINF GASTROENTERI (stomach virus) 5,037 789.09 ABDOMINAL PAIN-SITE NEC 4,773 780.6 FEVER 4,219 786.59 CHEST PAIN NEC 3,711 784.0 HEADACHE 3,248
  • 9. Trenton Health TeamHospital Utilization AnalysisSt Francis and Capital Health2010 - 2011 Ewing Royal Health Gate Nursing & Rehab 1314 Brunswick Ave Trenton Housing Authority 1,834 episodes 237 Oakland St 1,354 episodes Providence Nursing & Rehabilitation Center 439 Bellevue Ave 1,174 episodes ^ Rowan Tower 620 W State St ^ 1,065 episodes Luther Towers 489 W State St ^ ^^ 1,551 episodes ^ ^ 333 W State St 1,042 episodes ^ ^ Rescue Mission of Trenton Trenton 98 Carroll St 2,315 episodes Trent Center West 465 Greenwood Ave 1,335 episodes Trenton Center Apartments 511 Greenwood Ave 1,700 episodes 12
  • 10. Newark Beth Israel Hotspot Analysis (2010) Total Receipts by Zip Code 07112 $24,079,842 Total Costs per 07108 $16,553,538 Census Block (deciles) 07103 $14,181,330 $0 07106 $11,788,444 $1 - $1,097 07104 $7,022,274 $1,098 - $4,955 07114 $6,440,656 07107 $5,594,552 $4,956 - $10,700 07104 07105 $5,498,100 $10,701 - $18,685 07102 $4,206,927 $18,686 - $31,353 07107 $31,354 - $54,230 $54,231 - $88,719 1060 Broad St $88,720 - $167,531 (1 Building) $167,532 - $1,793,955 87 Patients Hotspot 198 ER & Inpatient Visits ^ (>$200k in receipts $993 thousand in receipts and >50 patients) 07106 07103 ^ ^ 07102 ^ 07108 ^ 07105 Mt Vernon and Manor Dr 07112 Elizabeth Ave High Rises (4 Buildings) ^^ High Rises (6 Buildings) 272 Patients 774 Patients 379 ER & Inpatient Visits 07114 1,390 ER & Inpatient Visits $1.11 million in receipts ^ $2.0 million in receipts SAINT BARNABAS HEALTH CARE SYSTEM13 Newark Beth Israel Medical Center
  • 11. £ ¤ 1 MaineCare Hotspot Analysis: Penobscot County § ¨ ¦ 95 7/1/2008 - 6/30/2010 Mount Chase Patten Stacyville Aroostook £ ¤ 2 North Penobscot Piscataquis Millinocket East Millinocket Medway Drew Kingman £ ¤ 201 Mattawamkeag High utilizer density Woodville £ ¤ 1 High Prentiss Webster § Chester ¨ ¦ 95 Winn Penobscot Carroll Seboeis Springfield Somerset Low Lincoln Lee Penobscot Indian Island Maxfield Lakeville Whitney What is a hot spot? Enfield Twombly Ridge A hot spot is any geography where a Howland 95 § ¨ ¦ Burlington Lowell large number of high utilizers reside. Passadumkeag LagrangeEdinburg High Utilizers are defined as any individual with 3 or more hospital East Central Penobscot Bradford admissions or 6 or more ER visits ArgyleGreenbush Washington GarlandCharleston Alton within 2 years. Hot spots range from Dexter blue (no hot spot) to red (intense hot Corinth Hudson Milford spot) Corinna Exeter Old Town KenduskeagGlenburn Stetson Levant Orono Bradley Hancock Newport Veazie BangorFranklin Hermon Eddington Clifton Carmel £§ ¤¨ ¦ Etna 395 Brewer Plymouth 202 Holden £ ¤ 201 £ ¤ 202 Hampden Newburgh Orrington £ ¤ 2 Clinton Dixmont 1£ ¤ ¤ Unity WaldoOxford Vienna Rome Oakland £ ¤ 201 Benton £ £ ¤ ¤ 1 1
  • 12. £ ¤ £ ¤ 201 § ¨ ¦ 95MaineCare Hot Spot Analysis: Kennebec County 201 Plymouth Etna7/1/2008 - 6/30/2010 Newburgh Franklin Somerset § ¨ ¦ 95 Dixmont Clinton £ ¤ 201 Unity Benton £ ¤ 2 Rome Oakland Vienna Waterville Winslow Albion Belgrade Waldo Mount Vernon Sidney Fayette Vassalboro China Oxford Readfield What is a hot spot? £ ¤ 201 A hot spot is any geography where a Wayne Manchester Augusta £ ¤ 202 large number of high utilizers reside. High Utilizers are defined as any Winthrop £ ¤ 201 Windsor individual with 3 or more hospital Hallowell admissions or 6 or more ER visits Androscoggin £ ¤ 202 Chelsea within 2 years. Hot spots range from Farmingdale 201£ ¤ blue (no hot spot) to red (intense hot Monmouth West Gardiner Randolph spot) § ¨ ¦495 Gardiner Pittston KnoxHigh utilizer density Litchfield High Lincoln Lincoln c § ¨ ¦495 £ ¤ 1 Low £ £ ¤ ¤ 1 Sagadahoc New Gloucester
  • 13. Overview of the Coalition!-  20 member board, incorporated non-profit!-  Foundation and hospital support!-  Structure of the Coalition:! -  Operations! -  Health Information Exchange! -  Research/Data/Evaluation! -  Finance/Admin/Legal! -  Programming! -  Citywide Care Management Project! -  Camden Chronic Disease/Primary Care Collaborative! -  Community-based Patient Engagement Strategies!
  • 14. Care Continuum Model! Hospital •  Mul.disciplinary  care  management  outreach  Admission •  Pa.ents  with  history  of  ED  visits/hospital  admissions   and  readmissions  (4  admits  w/in  6  mos.);  social   s Data! complexi.es   •  Average  6-­‐8  month  engagement   Inclusion! CCHP Outreach! Medical Home! Triage! High  Risk   Care  Coordina.on   Health  Coaching   Intermediate  Risk   Data  driven  care  mgt.   Pa.ent  Engagement   •  Nurse  driven  care  transi.on   •  Pa.ents  with  history  of  ED  visits/hospital  admissions   and  readmissions  (2+  admits  w/in  6  mos.);  socially   stable   •  Average  6-­‐8  week  engagement  
  • 15. Utilization typology Inpatient visits, 2011 ED visits, 2011 0 1 2 3 to 4 5+ 0 0 1,293 57 4 1 1 26,128 2,075 117 7 0 2 to 3 13,390 1,842 373 68 3 4 to 5 3,216 666 223 118 15 6 to 7 1,020 251 106 84 24 8 to 9 386 112 39 41 11 10 + 339 96 70 65 62
  • 16. Utilization typology Inpatient visits, 2011 ED visits, 2011 0 1 2 3 to 4 5+ 0 1 Normal Range of Utilization 2 to 3 Potential High Inpatient 4 to 5 Utilizers High Utilizers 6 to 7 Emergency Potential High Department Utilizers High Utilizers 8 to 9 10 +
  • 17. Utilization matrix Inpatient visits, 2011 ED visits, 2011 0 1 2 3 to 4 5+ 0 44,728 (85%) patients 5,210 Inpatient visits 63,489 ED visits 1 $28,000,000 (50%) IP payment $25,800,000 (59%) ED payment 2 to 3 985 (2%) patients 1,856 IP visits 503 (1%) patients 4,129 ED visits 2,026 Inpatient Visits 4,144 ED Visits 4 to 5 $10,000,000 (17%) IP 1,563 (3%) patients payment $10,900,000 (20%) in IP payment 1,239 IP visits 4,961(9%) patients 6,962 ED visits $1,700,000 (4%) ED $1,700,000 (4%)in ED payment 6 to 7 payments 28,447 ED visits $6,700,000 (18%) in IP $11,500,000 (27%) in payment 8 to 9 ED payment $2,800,000 (6%) in ED payment 10 +
  • 18. Patient A Es.mated  2011  Payment   ED:  $38,000  to  $76,000  (93  visits)     IP:  $65,000  to  $130,000  (12  visits)   Total:    $103,000  to  $206,000     Saving  Es.mates   30%  reduc.on  in  u.liza.on  :   ED:  -­‐28;  -­‐$11,000    to  -­‐$22,000   IP:  -­‐  4;        -­‐$19,000    to  -­‐$38,000  
  • 19. Train local residents toparticipate in decision-making over health care resources!
  • 20. Promote collaboration among providers andbetween providers and the community!
  • 21. Comparing Emergency Room High Utilizers in Camden, Trenton, and Newark!Emergency Department High Utilizers Top 1% 2007CamdenPatients 386Visits 5169Visits/Patient 13.4% visiting more than one hospital 80.6%TrentonPatients 504Visits 7616Visits/Patient 15.1% visiting more than one hospital 78.2%NewarkPatients 928Visits 14367Visits/Patient 15.5% visiting more than one hospital 71.1%
  • 22. SENATE, No. 2443STATE OF NEW JERSEY 214th LEGISLATURE INTRODUCED DECEMBER 6, 2010Sponsored by:Senator JOSEPH F. VITALEDistrict 19 (Middlesex)SYNOPSIS Establishes Medicaid Accountable Care Organization Demonstration Projectin DHS.CURRENT VERSION OF TEXT As introduced.
  • 23. The  Plan:  Compe1ng  ACOs   Lourdes  ACO  Cooper  ACO   Virtua  ACO  
  • 24. A  Different  ACO  Model  for   Camden  
  • 25. Camden cost savings strategies !1.  Nurse practitioner led clinics in high cost buildings!2.  More high utilizer outreach teams!3.  Medical home-based nurse care coordination!4.  More same day appointments (open access scheduling)!
  • 26. Lessons from Camden!n  Strategic ability to filter, focus, and segment!n  Comfort with ambiguity and willingness to tinker!n  Adaptive challenge not a technical challenge!n  Passion for moving towards standardization and efficiency when the time is right!n  Meaningful solutions are local, gradual, and require chunking!