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.

1. www.alliancefordiabetes.org

2. Merck Alliance to Reduce Disparities in Diabetes
Camden, NJ

3. Camden, NJ

4.  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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5. ED/Hospital Referrals
13 Primary Care Practices
Local Care Management Team
• Nurse practitioner
Citywide Care
Health Database • Social work case manager Management
• Community health worker/MA Committee
•Program manager
Camden Citywide Diabetes Collaborative
Patient-Family Centered
Outreach/Care and
Practice Transformation

6.  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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7.  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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8.  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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9.  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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10.  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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11.  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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12. ◦ Thank you
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