Care Management Program
An Initiative to Reduce Unnecessary Hospital Utilization in Camden
In 2007, the Coalition began implementation of a citywide Care Management Project to intervene and direct appropriate outreach attention to Camden’s most frequent utilizers of the city’s EDs and hospitals. These patients lack consistent primary care, often suffer from chronic illness, mental illness, and substance abuse.
Frequent utilizers visit multiple EDs seeking medical attention with little or no coordination of care across institutions. Thus, services and tests are often duplicated several times resulting in inefficient, uncoordinated, fragmented, and expensive care.
The Coalition’s Care Management and Care Transition Programs were designed to target high cost, complex patients for improved care transitions and care coordination using the embedded nurse care manager/medical home model from Geisinger and the Group Health Cooperative.
Our staff has segmented this patient population into two groups: those who have no source of primary care and typically have significant social and mental health issues; and those with more stable primary care and less severe social issues.
Both groups of patients are in need of a primary care medical home with the capacity to manage care transitions and provide care coordination.
The Coalition has developed a Citywide Collaborative of primary care, behavioral health, social service and other supportive service providers to improve care for this patient population.
Care Management Program
Care management patients are enrolled into our program after they are admitted to the hospital, in the community, or at their home or shelter.
Using an outreach team consisting of a social worker, a health outreach worker/medical assistant, and a nurse practitioner, our team helps enrolled clients stabilize their social environment and health conditions, with a goal of finding a primary care medical home.
The team assists with:
- Coordinating primary and specialty care
- Applying for government assistance benefits;
- Securing temporary shelter; and
- Enrolling in medical day programs
Out of necessity, our staff also provides “transitional” primary care with a goal of moving the patients into a primary care setting that can meet their needs. The program has touched hundreds of patients and the team visits patients in homeless shelters, abandoned homes, hospital rooms, ED gurneys, and on street corners.
Care Transitions Program
Care Transitions patients typically have a usual source of primary care and fewer social issues, but receive no care coordination services from their primary care providers.
The Care Transitions team, consisting of embedded care management nurses and health coaches, provides services to the patients of two Federally Qualified Health Centers (FQHC) in Camden – CAMcare and Project HOPE. Patients are typically enrolled in the Care Transitions Program after they are admitted to the hospital.
The Coalition is working with the two FQHC’s to help them become patient centered medical homes that will use nurse care coordinators to focus on patients needing care transitions.
As result of the program, new patterns of care transitions and care coordination are being developed between Camden’s hospitals and the FQHCs.
Utilizing Technology to Improve Care
The Care Management and Care Transitions Programs rely heavily on data from our Health Information Exchange (HIE). The teams receive real-time alerts on hospital and ER utilization from the HIE for targeted patients.
The teams use an Electronic Health Record (EHR) embedded in the HIE to record care management notes. With patient consent, healthcare providers and social workers across the city have access to these notes and can send encrypted messages for care coordination purposes. Aggregate clinical and utilization data is also exportable to identify additional care coordination opportunities.
Citywide Collaboration to Improve Care
The Coalition holds a monthly Care Management Committee meeting that rotates between the hospitals and is attended by social workers and other supportive services providers from across the city. This committee helped to oversee the development of the high utilizer team and continues to advise the Care Management Program.
Through the Coalition’s work with high utilizers the staff has built close relationships with emergency room physicians, hospitalists, specialists, social workers, and nurse discharge planners across the city. These relationships are crucial to the team’s success and ensure good discharge planning and care coordination upon discharge.