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Camden Citywide Diabetes Collaborative
Camden Citywide Diabetes Collaborative
Camden Citywide Diabetes Collaborative
Camden Citywide Diabetes Collaborative
Camden Citywide Diabetes Collaborative
Camden Citywide Diabetes Collaborative
Camden Citywide Diabetes Collaborative
Camden Citywide Diabetes Collaborative
Camden Citywide Diabetes Collaborative
Camden Citywide Diabetes Collaborative
Camden Citywide Diabetes Collaborative
Camden Citywide Diabetes Collaborative
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Camden Citywide Diabetes Collaborative

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

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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  • 1. Camden Coalition of Healthcare Providers___________________________Camden Citywide Diabetes Collaborative<br />
  • 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. Camden, NJ<br />
  • 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. Citywide Care Management System<br />ED/Hospital Referrals<br />13 Primary Care Practices<br />Local Care Management Team<br /><ul><li> Nurse practitioner
  • 6. Social work case manager
  • 7. Community health worker/MA
  • 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. 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. 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. 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. 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. 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. Portion of gains return to practices to enhance practice/heathcare
  • 15. Similar to Kaiser, Geisinger, and the Mayo clinic models</li></ul>10<br />
  • 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. Thank you<br />12<br />

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