The document outlines the scaling efforts of the Camden Coalition of Healthcare Providers (CCHP) care management program from 2007-2012. It began with a focus on super-utilizers of the emergency department and enrolled 50 patients in the first month. Over time, CCHP expanded the program to serve hundreds more high-cost patients, created a care coordination team, and obtained additional grants to embed nurses in community health centers and provide direct outreach to patients in the hospital. The care management workflow involved identifying high-risk patients from admission data, conducting outreach and enrolling them, providing interventions like home visits and medication reconciliation, and connecting patients to primary care. CCHP also focused on workforce development and establishing protocols

1. Camden Coalition of
Healthcare Providers
Scaling: Where to Begin?
July 31, 2013
Camden Coalition of
Healthcare Providers
www.camdenhealth.org

2. 2007
• New Jersey Health Initiatives funding
for 3 years
– Primary focus: ED “super-utilizers”
– Enroll 50 patients the first month
“once the details of the protocol are
finalized”
– 400 by the end of the 1st year, 600 by the
end of the 3rd year
“…remain in the intervention until their
needs have been met”
www.camdenhealth.org

3. • Developed CCHP Care Management
Team
– Served approx. 300 patients
• Created citywide care coordination
meeting
• Created infrastructure for citywide
health information exchange
www.camdenhealth.org

4. 2011
• NJHI-Care Transitions grant
– 400 high cost patients over 2 years
– 25% tier 1
– 75% tier 2
– Embed nurse care coordinators in local
FQHCs
www.camdenhealth.org

5. • Created 90 day workflow that directly
outreach to patients in the hospital
– Focus on inpatient admissions
• Daily data feed of Camden residents
with high hospital utilization
• RN led model
• High risk vs. low risk—no difference
www.camdenhealth.org

6. ED visits, 2011
Inpatient visits, 2011
0 1 2 3 to 4 5+
0
44,728 (85%) patients
5,210 Inpatient visits
63,489 ED visits
$28,000,000 (50%) IP payment
$25,800,000 (59%) ED payment
985 (2%) patients
1,856 IP visits
4,129 ED visits
$10,000,000 (17%) IP
payment
$1,700,000 (4%) ED
payments
503 (1%) patients
2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment
$1,700,000 (4%)in ED payment
1
2 to 3
4 to 5
4,961(9%) patients
28,447 ED visits
$11,500,000 (27%) in
ED payment
1,563 (3%) patients
1,239 IP visits
6,962 ED visits
$6,700,000 (18%) in IP
payment
$2,800,000 (6%) in ED
payment
6 to 7
8 to 9
10 +
6www.camdenhealth.org
Camden Hospital Utilization Typology
Understand
the
problem

7. 2012
• CMMI/Health Care Innovation Award
– Awarded approx. $3 million
– Generate $6 million in savings
– Serve over 800 patients over 3 years
www.camdenhealth.org

8. APN SW CHWPMStart up
Staff Composition
RN
LPN
LPN
CHW
HC
HC
Pr. Dir.
SW
Outreach
Specialist
www.camdenhealth.org

9. Staff Composition
RN
LPN
LPN
CHW
HC
HC
Pr. Dir.
SW
Intervention
Specialist
www.camdenhealth.org
RN
LPN
LPN
CHW
HC
HC

10. Care Management Workflow
•Admissions
data
•Current day
•Access to
patient chart
Data
•Assessment
•Assignment
Triage
•Blend of
medical &
social
complexity
Outreach
•Completion
of care plan
•Transition to
PCP
Graduation
Patients Flagged:
• 2+ hospital
admissions < 6
months
Selection Criteria:
• History of chronic
disease related
admits
• Rule out criteria
• Validate risk score
• Assigned to
outreach team
Intervention:
• Bedside
outreach/enrollment
• Home visit w/in 48
hrs of d/c
• PCP w/in 7 days
• Front load nursing
outreach, followed
by social outreach
Discharge
• Deceased
• Moved
• Lost contact
• Disengaged
www.camdenhealth.org

11. Guiding Principles
• Enroll patients based on data; history of
repeat admissions (high cost) and specific
inclusion criteria
• Provide immediate and intensive follow-up
coordination post discharge; connect patient
to PCP as quickly as possible (target = 7 days
post d/c)
• Dramatically improve the relationship between
patient/family and PCP & specialists
• Equal focus of intervention on coaching
www.camdenhealth.org

12. Key Intervention:
Home-Based Medication Reconciliation
www.camdenhealth.org

13. Mentoring/Workforce Development
• Flexibility
• Clear goals and expectations
• Protocols
• What other resources are need to
address team composition/staff
structure?
www.camdenhealth.org

14. Link2Care/CMMI team