Camden Citywide Diabetes Collaborative

Camden Coalition of Healthcare Providers___________________________Camden Citywide Diabetes Collaborative

Innovation in reaching those at highest risk through information exchange across community care delivery systems
Merck Alliance to Reduce Disparities in Diabetes
Camden, NJ

Camden, NJ

Project Focus:
Care management of complex patients w/ diabetes
Diabetes Self Management Education (DSME)
Practice Transformation based on PCHH
Health Information Technology (HIT)
Evolution into an Accountable Care Organization (ACO)
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Citywide Care Management System
ED/Hospital Referrals
13 Primary Care Practices
Local Care Management Team
Nurse practitioner
Social work case manager
Community health worker/MA
Program manager
Citywide Care Management Committee
Health Database
Camden Citywide Diabetes Collaborative
Camden Citywide Diabetes Collaborative
Patient-Family Centered Outreach/Care and Practice Transformation

Transforming Primary Care
Improve the capacity of primary care practices (PCP) in Camden to provide comprehensive, proactive care to their patients with DM
Transition PCP to Patient-Centered Healthcare Homes
Increase number of ADA Education sites
Citywide DSME referral form
Implement a patient registry, EHR, group DM visits, open access scheduling, on-site nutrition/DM education, Teachable Moments
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Transforming Primary Care (cont’d)
Utilize community outreach staff to provide self-management support to patients
Conduct peer-to-peer learning and PI
Professional Education Opportunities with CEs
Coaching, support, and consultations to the PCP
Assist practices with collecting, utilizing, and reporting quality patient data
Helped to pass legislation in NJ for ACO model of healthcare delivery
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Camden Health Information Exchange (CHIE)
System allows Camden healthcare providers to access patient health information in real time
Initiated April 2009- ‘Go Live’ was Nov 2010
Provides labs, radiology reports, and discharge summaries from Cooper, Lourdes, and Virtua Hospitals, LabCorp, and Quest Diagnostics for patients living in Camden
$50,000 in direct contributions from the 3 Camden hospitals
$900,000 in Federal funds
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Camden Health Information Exchange (CHIE)
Potential Impact on Diabetes Care
Most current DM data for optimal care coordination
Data matching between practices and hospital data (health database, HIE)
Collection of health outcome metrics used for practice quality improvement
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Accountable Care Organizations (ACOs)
An integrated care delivery organization, in a defined geographic region, involving multiple primary care offices and least one hospital
Provide care management to high needs patients
Collaboration with healthcare and social service providers
Relationships with PCPs with capacity building
Manage hospitalization/specialty care
Improved health outcomes result in health care cost savings w/ gainsharing
Portion of gains return to practices to enhance practice/heathcare
Similar to Kaiser, Geisinger, and the Mayo clinic models
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Accountable Care Organizations (ACOs)
Statewide Progress
Greater Newark Healthcare Coalition incorporated, Trenton close
White paper published
Four pro-bono healthcare attorneys drafted legislation
Lobbyist hired by NJ Chamber of Commerce
Passed by assembly in early 2011
Statewide ACO conference in January 2011
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Thank you
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Camden Citywide Diabetes Collaborative

by Center for Managing Chronic Disease

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Camden Citywide Diabetes Collaborative Presentation Transcript