• In one year, approximately half of all Camden residents visited the ER (2003)
• Camden rate of ER visits = 55%; national rate in U.S. = ~25-30%; Canada = ~19%
• Large number of visits are for preventable conditions that can be appropriately managed in the primary care setting
• 73% of all visits are by insured patients
• 20% of the patients are responsibile for 50% of all visits to the hospitals; one Camden resident made over 115 visits in one year
• 13% of the patients were responsible for 80% of the total costs
• The most expensive patient (2002-07) resulted in $3.5 million in payment to hospitals through Medicaid and Medicare

Care Management for High Utilizers

The Camden Coalition of Healthcare Providers has created a citywide Care Management Project to help intervene and direct appropriate outreach attention to the highest utilizers of Camden's EDs and hospitals. Referred by ED and inpatient social workers/nurses/physicians, these individuals typically have complex medical conditions compounded by an array of social issues and problems. They constantly go from ED to ED in search of the help they need and because there is no coordination of care across institutions, care is often duplicated several times.  The result is an inefficient, uncoordinated, fragmented, and expensive system of care.

The project seeks to provide targeted care management to these patients. We enroll patients who are referred to us by hospital providers and social workers. With a team consisting of a social work case manager, a health outreach worker, and a nurse practitioner, the Care Management Project will help enrolled clients towards stablizing their social environment and finding a medical home. We will help patients apply for government assistance benefits, secure temporary shelter, enroll in medical day programs, help coordinate primary and specialty care, and our nurse practitioner will provide in-home (or in-shelter) transitional care.

Using hospital data, we can monitor patient utilization behavior over time and measure the impact of the project’s activities. In addition, we hold monthly Care Management Committee meetings to present patient cases and discuss the systemic issues and barriers to care that each case addresses. In a forum of providers and social workers from all of Camden health institutions, we emphasize information and resource sharing and developing collaborative strategies to make Camden’s health systems more effi cient and accessible for city residents.

Refer Patients

If you are a nurse, social worker, or physician and have a patient who is a Camden resident and:

• Has had 6 visits to the hospital or ED in one year
• and/or has spent 45 days or more in the hospital in one year
• or in your opinion is likely to either of the above...

Refer him/her to the Care Management Project for possible enrollment.

Download and complete referral form and fax to: 968-6216