An Initiative to Reduce Unnecessary ED 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, substance abuse, and as a result are the most frequent visitors to city emergency departments. Typically, these overutilizers or “super users” 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  with little or no coordination of care across institutions, care is often duplicated several times over. The result is an inefficient, uncoordinated, fragmented, and expensive system of care.

Using a outreach team consisting of a social worker, a health outreach worker/medical assistant, and a nurse practitioner, the Care Management Project helps enrolled clients  stabilize their social environment and health condition, with a goal of finding a long-term medical home. The team helps patients apply for government assistance benefits, secure temporary shelter, enroll in medical day programs, help coordinate primary and specialty care. Out of necessity, the staff is providing “transitional” primary care with a goal of moving the patients into a primary care setting that can meet their needs. With over 115 patients enrolled in the project, the staff is visiting patients in homeless shelters, abandoned homes, hospital rooms, ED gurneys, and street corners.

Citywide Collaboration to Improve Care

The advantage of the project’s citywide scope is the ability to encourage collaboration between the hospitals, to share data, to identify common challenges, and to address the challenges with coordinated solutions. Monthly, the team coordinates a citywide Care Management meeting that allows providers and social workers from all of Camden’s health institutions to present patient cases and discuss the systemic issues and barriers to care that each case addresses. Information and resource sharing are encouraged as providers and social workers develop collaborative strategies to make Camden’s health systems more efficient and accessible for city residents. Participants have formed a coordinated network of social services, discharge planning, and health care delivery.

From the relationships built at the staff level, between competing hospitals, our “super utilizers” are receiving a much higher level of coordinated care. Daily phone calls go back and forth between the social workers of these institutions discussing medical histories, social work issues, and discharge planning. When one of the Coalition’s patients is admitted, hospital social workers immediately alert the Coalition’s staff. Often Coalition staff are able to intervene while the patient is still in the emergency room to make sure the patient gets his or her care needs met.

ER and hospital overutilization is like any maladaptive health behavior, it requires time and compassion to effect change. Vulnerable, high utilizing patients do not choose to be frequent utilizers of the ED, but they do not know how else to get their needs met. For many of the patients, with a few months of frequent outreach visits, aggressive treatment of depression, education and close management of their chronic illnesses, assistance with applications for public benefits, and help with their social issues, the staff have seen utilization drop significantly.

For more information about the Camden Care Management Project, please contact us.