1. Improving Diabetes Outcomes for High-Utilizing Patients in Camden
ABSTRACT
Goals: The Camden Coalition of Healthcare Providers’ (CCHP) ultimate aim is the reduction of health
care costs through improved care coordination. It targets patients with these specific goals:
1) Identify patients suitable for enrollment through the Camden Health Informaiton Exchange (HIE)
2) Use of a Care Transitions outreach team for home assessment and effective transition from the hospital
3) Improve clinical outcomes and process measures such as attendance to DSME classes and improved
adherence to primary care visits
4) Decreased rates of ER and hospital use
Method: Patients with excess ER and inpatient hospital admissions were identified for the program
through the Camden Health Information Exchange (HIE). Patients who meet the criteria are enrolled at
bedside for a 30-90 day intensive care coordination intervention.
Target Population: Camden City residents with at least two ER visits or hospital admissions
within 6 months and chronic co-morbidities.
Outcome Measures: Measuring clinical outcomes such as: HbA1c, lipids and blood pres-
sure; number of patients attending DSME; reduction in the number of preventable hospitalizations.
Evaluation Results: In a six year period (2002-2008), a total of 7,041 patients with diabetes
utilized area ER and hospitals for a total of 62,560 visits. Charges totaled $1,550,429,036.37 with re-
ceipts of $203,716,769.83. Among several patients, there was a dramatic decline of ER and hospital utili-
zation from pre-enrollment to post-enrollment, some without any utilization.
Preliminary analysis shows that of the 25 patients enrolled in the Care Transitions program, approximately
25% have diabetes as a comorbidity. For n=21 patients, there was a 57% decrease in both ER and ospi-
tal utilization post-enrollment. For ER utilizations, there was an average of $925 per month of charges
before enrollment and $0 per month after enrollment while for in-patient admissions, there was an aver-
age of $22,225 per month of charges before enrollment and $0 per month after enrollment in the pro-
gram.
INTERVENTION RESULTS
FACILITATING/HINDERING
FACTORS
TARGET POPULATION
Data from a Camden City Comprehensive Health Database (July 2002 - June 2008)
17.0%
08102
15.6%
08103
12.7%
08105
11.6%
08104
percent of population with at least 1 visit
Visits by Diabetics by ZIP
Visits by Diabetics by Hospital
Cooper
31,814
OLOL
22,897
Virtua
7,849
11.6% - 12.7%
15.6%
17.0%
E.D.
Visits
Inpatient
Visits % Inpatient
Diabetes 39,946 22,610 57%
Overall 386,093 79,088 20%
Visits Patients Visits /
Patient
Diabetes 62,560 7,041 8.89
Overall 465,203 103,706 4.49
Number
ofVisits
Total
Visits
Total
Patients Charges
1 to 10 22,075 5,270 $674,344,336.42
11 to 20 16,134 1,126 $431,920,873.45
Over 20 24,351 645 $444,163,826.50
Receipts
$92,597,330.57
$55,148,779.38
$55,970,659.88
TOTAL 62,560 7,041 $1,550,429,036.37 $203,716,769.83
Facilitating Factors:
• Longitudinal relationship based on rapport and trust between patients and outreach team
• Having a proactive holistic model of care that is focused on respect and non-judgment
• Strong relationship and support from community partnerships
• Community-based problem-solving
Hindering Factors:
• Patient barriers such as language, insurance, readiness for behavior change, and food security
• Scheduling follow-up appointments within one week with primary care
• Tracking down at-risk patients
Transitions of Care 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-discharge)
• Dramatically improve the relationship between patient and PCP
• Equal focus of intervention on health coaching
Outreach Team Composition:
High Risk Outreach Team Intermediate Risk Outreach Team
RN RN
MA LPN
Social Worker Health Coaches
Health Coaches
Patient Selection:
• History of 2+ admissions within past 6 months
• History of chronic disease related admits
• Socially stable
• Rule-out criteria
o Oncology
o Pregnancy
o Acute Trauma
o Psych only diagnosis
o Surgical Operation
Division of Work (0-30 days post)
Nursing Health Coaches
Clinical assessment Make appointments
Medication reconciliation Transportation enrollment &
training
Establish care plan; identify patient
goals
Nutritional support AND food
security
Accompanied PCP and specialty
care follow up appointments
Mobility assistance
Follow-up home visits; care
provider reinforcement
Accompaniment
Establish Health Coach plan for
second phase
Division of Work (30-90 days post)
Nursing Health Coaches
Medication reconciliation Logistics: make own
appointments, arrange own
transportation, access specialty
care
Chronic disease maintenance Disease self management:
awareness of chronic disease
maintenance, can communicate
with provider(s) and navigate an
agenda
Handle readmissions Social skills: can find resources, life
management skills
Schedule hand-off appointment;
graduation to PCP
Ongoing social support
Care Transitions time-
line and workflow.
Patients are identified as candidates for the
program through a daily feed from the Health
Information Exchange.
INTRODUCTION
Preliminary Analysis:
• 25% of patients (n=21) enrolled in Care Transitions have diabetes as a co-morbidity
• There was a 57% decrease in both ER and hospital utilization post-enrollment across all patients
• ER utilizations decreased from an average of $925/month of charges to $0 per month after
enrollment
• In-patient admissions decreased from an average of $22,225 per month of charges to $0 per
month after enrollment
Patient Utilization EKG*
*Utilization EKG’s are used to graphically represent patient ER and in-
patient hospital utilization and cost for individual patients. This example
shows a diabetic patient whose utilization fell to zero after being enrolled
in the Care Transitions program.
The Care Transitions Program has been successful in reducing both ER visits and in-patient hospitalizations. This
has been accomplished by strong team dynamic, benchmarking progress, standardizing discharge plans, and
quick and intense follow-up post-discharge. Our success also underscores the importance of a trusting healing
relationship between provider and patient and the ability to coordinate across a number of public services and
medical offices.
CONCLUSION
CCHP is a nine-year old strategic initiative with a mission to improve the quality, capacity, and ac-
cessibility of the healthcare system for vulnerable populations in Camden, NJ. In 2011 the Care Transi
tions Program, borne out of the Care Management Project, was created. It is a 30-90 day intervention
targeting high cost, medically complex patients. These patients lack consistent primary care; often
suffer from chronic co-morbidities, including diabetes. This is a report on the process and current out
comes of the Care Transition outreach teams (consisting of a Registered Nurse, Licensed Professional
Nurse and AmeriCorps health coaches) and their impact on the healthcare delivery in Camden.
Steven Kaufman MD; Nadia Ali MPA; Victoria DeFiglio RN, BSN; Jason Turi RN, MPH; Maechiel Lluz