1. Improving Care Together
in One of America’s
Poorest Cities
S
Jeffrey Brenner, MD
Executive Director
2. Understanding the Problem
• 55-yo Male, admitted for GI bleed
and SOB (November 2011)
• Dual coverage, Lives alone in
high-rise apartment
• 6 months: 9 ED visits, 6 inpatient visits
• 12 medications daily
3. Patient Centered Care Coordination
Transport
Meals Home
PT/OT Home
Nursing
Hospita
Sub-Acute l #2
Rehab
Durable Hospita
Goods l #1
Patient
Dialysis
PCP
Urology
Nephrology Oncology
Surgery
Optho
Transplant
Pain Cardiology
Mgt GI
9. Overview of the Camden Coalition
of Healthcare Providers
Mission: To improve the quality, capacity, coordination and
accessibility of the healthcare system for all residents of
Camden.
Vision: Camden will be the first city in the country to bend the
cost curve while improving quality.
• 50 staff, $4.8 million annual budget
• Mix of foundation, federal grant funding and hospital
support
• Membership organization, 20 member board, incorporated
non-profit
11. Data
Segmentation
Geography
Utilization
Primary Care Provider
Real-time
12.
13. Camden Health Data
2011 with Lourdes, Cooper, Virtua data
• 52 % population use ER/hospital in one year
Leading ED/hospital utilizers citywide
• 324 visits in 5 years
• 113 visits in 1 year
Total revenue to hospitals for Camden residents
$108 million per year
• Most expensive patient $3.5 million
• 26% costs = 1% patients
• 58% costs = 5% patients
• 73% costs = 10% patients
14. Top Camden ER Diagnosis 2011
465.9 ACUTE UPPER RESPIRATORY 4,858
INFECTION (head cold)
848 SPRAINS AND STRAINS 3,295
861.11 CONTUSION 2,786
789.0 ABDOMINAL PAIN-SITE NEC 2,318
686.9 SKIN AND TISSUE INFECTION 2,213
599.0 URINARY TRACT INFECTION 2,182
721.9 SPONDYLOSIS/BACK PROBLEMS 1,735
493.9 ASTHMA 1,580
15. Clinical Redesign
Henry Ford Effective
Assembly
Efficient Line
Scientific Management
Reliable
Six Sigma Work Flows
17. The Carry: Community Based Care
Coordination
Data Triage Outreach Graduation
Discharge
• Deceased
• Moved
• Lost contact
• Disengaged
18. Daily Admissions Feed
Admitted past month, 6 month summary
Days 6 mo episodes
Admit Facility Inp ED Name dob age sex PCP PracticeName Insurance
06/13/12
Cooper 40 7 3 xxxxxxxxxxxxxx xx/xx/xxxx 55 M JACK GOLDSTEIN CMC Dept of
Cooper 44 3 2 xx/xx/xxxx 73 F MARILYN GORDON CAMcare Health
Cooper 79 3 xx/xx/xxxx 57 M JOHN KIRBY Cooper Physician HORIZON NJ PPO
Cooper 35 2 3 xx/xx/xxxx 21 M NO PHYSICIAN
OLOL 1 2 1 xx/xx/xxxx 56 M SELF PAY -
Cooper 5 2 1 xx/xx/xxxx 61 M
OLOL 4 2 1 xx/xx/xxxx 54 M SELF PAY
Cooper 27 2 xx/xx/xxxx 47 M MARILYN GORDON CAMcare Health
06/12/12
Cooper 15 13 1 xx/xx/xxxx 22 F MIGUEL MARTINEZ Cooper Physician
Cooper 18 3 2 xx/xx/xxxx 55 M NO PHYSICIAN AMERHLTH/KEYST
Cooper 99 3 1 xx/xx/xxxx 64 M DANIEL HYMAN Cooper Physician
06/11/12
Cooper 9 9 5 xx/xx/xxxx 48 M LYNDA BASCELLI Project Hope
OLOL 43 9 1 xx/xx/xxxx 71 F INTERNAL BILLING
OLOL 17 5 5 xx/xx/xxxx 66 F HORIZON NJ
Cooper 27 5 3 xx/xx/xxxx 52 M LYNDA BASCELLI Project Hope
OLOL 35 5 1 xx/xx/xxxx 70 F BRAVO HEALTH
OLOL 46 4 5 - xx/xx/xxxx 73 F HORIZON NJ
OLOL 31 3 2 xx/xx/xxxx 52 F SELF PAY
Cooper 2 3 1 xx/xx/xxxx 68 F MINH HUYNH
OLOL 1 3 1 xx/xx/xxxx 73 F HORIZON NJ
Cooper 34 3 xx/xx/xxxx 62 F ANNA HEADLY Cooper Physician
Cooper 131 2 10 xx/xx/xxxx 35 M NO PHYSICIAN
OLOL 54 2 6 xx/xx/xxxx 49 F SELF PAY -
OLOL 177 2 4 xx/xx/xxxx 91 F HORIZON NJ
Cooper 3 2 2 xx/xx/xxxx 51 M NO PHYSICIAN MEDICAID
OLOL 139 2 2 xx/xx/xxxx 87 F HORIZON NJ
Thursday, June 14, 2012 Page 1 of 8
www.camdenhealth.org
19. The Catch: Primary Care Redesign
Daily
hospitalization
data
Outreach
Appointment
within 7 days
Care plan
20. Engagement
Policymakers Residents
Providers
Patients
Community Resources
Faith-Based Groups Advocates
Payors Colleagues
24. What Does Good Care Look Like?
• Accessible Examples
• Responsive PACE Program
• Personalized ACT Team
• Community-based Nurse Family Partnership
• Integrated Ryan White Clinic
• Holistic Health Quality Partners
Clinical Redesign: Reform the healthcare system to deliver good care, especially to those with multiple chronic conditionsData: Looking at patient and population data to identify issues, design interventions, and evaluate effectivenessEngagement: Forging relationships between patients, providers, and community partners
“The Push” Communicating with hospitals to facilitate the hospital to community handoff“The Carry” Community-based care coordination for high risk/high needs patients post discharge “The Catch” Primary care redesign; analyzing and modifying workflows to provide proportional care to high-needs patients
Data: Near real-time admissions dataTargets admission as the triggerTriage:AssessmentAssignmentOutreach: Blend of medical & social complexityGraduation: Completion of care planTransition to PCP
AccessChronically ill patients needs access to their providers as issues ariseCoordinationMuch of the coordination of care can be carried out by Nurses, LPNs, MAs, and Health CoachesConnecting patients and providers to readily available resourcesDataRegistriesTargeted interventions- EHRs, scheduling software, and billing data all have an enormous amount of information that can be analyzed to target outreach OutreachBuilding relationships in the primary care office and at the homeProtocols and StandardizationProviders can protocolize and standardize their tasks and delegate to other team members
Camden will be the first city in the US to bend the cost curveIntense city-wide care management program900 patients over 3 yearsRedesigning doctor office activitiesHIE, diabetes classes, physician education, patient registriesEngaging community partners to identify next interventions
Camden will be the first city in the US to bend the cost curveIntense city-wide care management program900 patients over 3 yearsRedesigning doctor office activitiesHIE, diabetes classes, physician education, patient registriesEngaging community partners to identify next interventions
