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Camden Citywide Care Management Project

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Citywide Care Management Meetings

The Care Management Project depends on the collaboration of health providers, social workers, administrators, social service providers, and other stakeholders from a variety of institutions, organizations, and practices across the city.  The Coalition holds monthly Care Management meetings to present anonymous cases of super-utilizing patients, discuss systemic barriers to care and to collaboratively strategize on a plan of care.  The group welcomes physicians, nurses, social workers, and Camden service providers to join, share resources, and discuss how to improve the efficiency and coordination of care for these patients.

The meetings are held on the 4th Wednesday of every month 9:00a - 10:00a (view schedule for meeting dates and locations).  For more information, call (856) 968-9500.


Some Background Statistics

  • 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 Camden "Super-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 "super-utilizers" 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 efficient and accessible for city residents.

Read About the Care Management Project

March 22, 2009
Coalition Helping Patients pdf
Courier Post

March 9, 2009
An ER Alternative
  pdf
Philadelphia Inquirer

Provider Team Offers Services and Referrals to Frequent Emergency Department Users 
in Inner City, Leading to Anecdotal Reports of Lower Utilization

Project profile by AHRQ Health Care Innovations Exchange

October 12, 2008
Medical Plan Aids Patients, Hospitals  pdf
Courier Post

July 13, 2008
Repeat 'Super Users' are Swamping the ER  pdf
The Star Ledger

June 2008
Camden Care Management Project Evaluation  pdf
Initial findings from the Care Management Project (project summary)

 

 
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