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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.
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.
