Camden Citywide Diabetes Collaborative

www.alliancefordiabetes.org

Merck Alliance to Reduce Disparities in Diabetes Camden, NJ

Camden, NJ

Project Focus:

Care management of complex patients w/ diabetes

Diabetes Self Management Education (DSME)

Practice Transformation based on PCHH

Health Information Technology (HIT)

Evolution into an Accountable Care Organization (ACO)

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ED/Hospital Referrals

13 Primary Care Practices

Citywide Care

Management

Committee

Local Care Management Team

• Nurse practitioner

• Social work case manager

• Community health worker/MA

•Program manager

Patient-Family Centered

Outreach/Care and

Practice Transformation

Health Database

Camden Citywide Diabetes Collaborative Camden Citywide Diabetes Collaborative

Transforming Primary Care ◦ Improve the capacity of primary care practices (PCP) in

Camden to provide comprehensive, proactive care to their patients with DM

◦ Transition PCP to Patient-Centered Healthcare Homes ◦ Increase number of ADA Education sites

◦ Citywide DSME referral form

◦ Implement a patient registry, EHR, group DM visits, open

access scheduling, on-site nutrition/DM education, Teachable Moments

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Transforming Primary Care (cont’d) ◦ Utilize community outreach staff to provide self-

management support to patients

◦ Conduct peer-to-peer learning and PI

◦ Professional Education Opportunities with CEs

◦ Coaching, support, and consultations to the PCP

◦ Assist practices with collecting, utilizing, and reporting quality patient data

◦ Helped to pass legislation in NJ for ACO model of healthcare delivery

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System allows Camden healthcare providers to access patient health information in real time

Initiated April 2009- ‘Go Live’ was Nov 2010

Provides labs, radiology reports, and discharge summaries from Cooper, Lourdes, and Virtua Hospitals, LabCorp, and Quest Diagnostics for patients living in Camden

$50,000 in direct contributions from the 3 Camden hospitals

$900,000 in Federal funds

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Potential Impact on Diabetes Care ◦ Most current DM data for optimal care coordination

◦ Data matching between practices and hospital data (health database, HIE)

◦ Collection of health outcome metrics used for practice quality improvement

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An integrated care delivery organization, in a defined geographic region, involving multiple primary care offices and least one hospital

◦ Provide care management to high needs patients ◦ Collaboration with healthcare and social service providers ◦ Relationships with PCPs with capacity building ◦ Manage hospitalization/specialty care

Improved health outcomes result in health care cost savings w/ gainsharing

Portion of gains return to practices to enhance practice/heathcare

Similar to Kaiser, Geisinger, and the Mayo clinic models

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Statewide Progress ◦ Greater Newark Healthcare Coalition incorporated, Trenton close

◦ White paper published

◦ Four pro-bono healthcare attorneys drafted legislation

◦ Lobbyist hired by NJ Chamber of Commerce

◦ Passed by assembly in early 2011

◦ Statewide ACO conference in January 2011

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◦ Thank you

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