af4 q 7_30_2013

Camden Coalition of

Healthcare Providers

Scaling: Where to Begin?

July 31, 2013

Camden Coalition of

Healthcare Providers

www.camdenhealth.org

2007

• New Jersey Health Initiatives fundingfor 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”


• Developed CCHP Care Management

Team

– Served approx. 300 patients

• Created citywide care coordination

meeting

• Created infrastructure for citywide

health information exchange


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


• 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


ED visits, 2011

Inpatient visits, 2011

0 1 2 3 to 4 5+

044,728 (85%) patients

5,210 Inpatient visits

63,489 ED visits

$28,000,000 (50%) IP payment

$25,800,000 (59%) ED payment985 (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

2012

• CMMI/Health Care Innovation Award

– Awarded approx. $3 million

– Generate $6 million in savings

– Serve over 800 patients over 3 years


APN SW CHWPMStart up

Staff Composition

RN

LPN

LPN

CHW

HC

HC

Pr. Dir.SW

Outreach

Specialist


Staff Composition

RN

LPN

LPN

CHW

HC

HC

Pr. Dir.SW

Intervention

Specialist


RN

LPN

LPN

CHW

HC

HC

Care Management Workflow

•Admissions data

•Current day

•Access to patient chart

Data•Assessment

•AssignmentTriage

•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


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


Key Intervention:

Home-Based Medication Reconciliation


Mentoring/Workforce Development

• Flexibility

• Clear goals and expectations

• Protocols

• What other resources are need to

address team composition/staff

structure?


Link2Care/CMMI team

af4 q 7_30_2013

Health & Medicine