Camden Citywide Diabetes Collaborative

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Aligning to Improve Outcomes: The Alliance to Reduce Disparities in Diabetes

A presentation from a symposium at the Centers for Disease Control and Prevention’s (CDC) Division of Diabetes Translation's (DDT) 34th annual Diabetes Translation Conference on April 11-14, 2011 in Minneapolis, Minnesota.

Published in: Health & Medicine, Business
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Camden Citywide Diabetes Collaborative

  1. 1. Camden Coalition of Healthcare Providers___________________________Camden Citywide Diabetes Collaborative<br />
  2. 2. Innovation in reaching those at highest risk through information exchange across community care delivery systems<br />Merck Alliance to Reduce Disparities in Diabetes<br />Camden, NJ<br />
  3. 3. Camden, NJ<br />
  4. 4. Project Focus:<br />Care management of complex patients w/ diabetes<br />Diabetes Self Management Education (DSME)<br />Practice Transformation based on PCHH<br />Health Information Technology (HIT)<br />Evolution into an Accountable Care Organization (ACO)<br />4<br />
  5. 5. Citywide Care Management System<br />ED/Hospital Referrals<br />13 Primary Care Practices<br />Local Care Management Team<br /><ul><li> Nurse practitioner
  6. 6. Social work case manager
  7. 7. Community health worker/MA
  8. 8. Program manager</li></ul>Citywide Care Management Committee<br />Health Database<br />Camden Citywide Diabetes Collaborative<br />Camden Citywide Diabetes Collaborative<br />Patient-Family Centered Outreach/Care and Practice Transformation<br />
  9. 9. Transforming Primary Care<br />Improve the capacity of primary care practices (PCP) in Camden to provide comprehensive, proactive care to their patients with DM<br />Transition PCP to Patient-Centered Healthcare Homes<br />Increase number of ADA Education sites<br />Citywide DSME referral form<br />Implement a patient registry, EHR, group DM visits, open access scheduling, on-site nutrition/DM education, Teachable Moments<br />6<br />
  10. 10. Transforming Primary Care (cont’d)<br />Utilize community outreach staff to provide self-management support to patients <br />Conduct peer-to-peer learning and PI<br />Professional Education Opportunities with CEs<br />Coaching, support, and consultations to the PCP <br />Assist practices with collecting, utilizing, and reporting quality patient data<br />Helped to pass legislation in NJ for ACO model of healthcare delivery<br />7<br />
  11. 11. Camden Health Information Exchange (CHIE)<br />System allows Camden healthcare providers to access patient health information in real time <br />Initiated April 2009- ‘Go Live’ was Nov 2010<br />Provides labs, radiology reports, and discharge summaries from Cooper, Lourdes, and Virtua Hospitals, LabCorp, and Quest Diagnostics for patients living in Camden<br />$50,000 in direct contributions from the 3 Camden hospitals<br />$900,000 in Federal funds<br />8<br />
  12. 12. Camden Health Information Exchange (CHIE)<br />Potential Impact on Diabetes Care<br />Most current DM data for optimal care coordination<br />Data matching between practices and hospital data (health database, HIE)<br />Collection of health outcome metrics used for practice quality improvement<br />9<br />
  13. 13. Accountable Care Organizations (ACOs)<br /><ul><li>An integrated care delivery organization, in a defined geographic region, involving multiple primary care offices and least one hospital</li></ul>Provide care management to high needs patients<br />Collaboration with healthcare and social service providers<br />Relationships with PCPs with capacity building<br />Manage hospitalization/specialty care<br /><ul><li>Improved health outcomes result in health care cost savings w/ gainsharing
  14. 14. Portion of gains return to practices to enhance practice/heathcare
  15. 15. Similar to Kaiser, Geisinger, and the Mayo clinic models</li></ul>10<br />
  16. 16. Accountable Care Organizations (ACOs)<br />Statewide Progress<br />Greater Newark Healthcare Coalition incorporated, Trenton close<br />White paper published<br />Four pro-bono healthcare attorneys drafted legislation<br />Lobbyist hired by NJ Chamber of Commerce<br />Passed by assembly in early 2011<br />Statewide ACO conference in January 2011<br />11<br />
  17. 17. Thank you<br />12<br />

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