Camden Citywide Diabetes Collaborative
The Camden Coalition of Healthcare Providers is an organization that seeks to improve the quality, capacity and accessibility of the health care system for vulnerable, chronically ill residents of Camden, N.J. The Coalition’s activities focus on community outreach, care management of high-needs patients, health care provider education, practice management capacity-building, data collection and evaluation and coalition-building among key stakeholders. The Camden Citywide Diabetes Collaborative has made use of the Coalition’s existing relationships and project strategies to pursue citywide coordination of services and care for city residents with diabetes. The project seeks to fundamentally change how providers, office staff and community agencies in Camden care for city residents with diabetes by building an accessible, high-quality, coordinated and data-driven health care delivery system with a strong primary care base.
Goals
- Improve the capacity of community-based, primary care practices to provide comprehensive, proactive care to their patients with diabetes
- Facilitate the certification of 10 community-based, primary care practices in Camden as Patient-Centered Medical Homes by the Nationa Committee for Quality Assurance (NCQA) and as American Diabetes Association (ADA) Education Recognition Program (ERP) sites
- Assist practices in implementing a diabetes registry, electronic health records, group diabetes visits, open-access scheduling, on-site nutrition and diabetes education, patient support programs and other tools for effective diabetes management
- Improve diabetes self-management for the residents of Camden
- Tailor culturally oriented diabetes self-management education programs
- Expand bilingual (English/Spanish) community health education forums with a focus on diabetes self-management education, nutrition, healthy lifestyles and self care
- Implement a monthly series about diabetes self management on the local cable access channel
- Distribute audio and video patient education materials to people with diabetes and their families
- Improve coordination of care for people living with diabetes across the city of Camden
- Develop standard outpatient, emergency department and hospital order sets for the management of patients with diabetes
- Work with information technology collaborators to develop a citywide diabetes patient registry and chronic disease dashboard
Approach
Since 2007, the Coalition has coordinated a citywide project to provide care management and transitional primary care for city residents who are the highest users of Camden’s emergency departments and hospitals. Guided by an expansive database of patient-level claims data from these facilities, the Coalition has created a program structure that is collaborative, patient-centered and data-driven.
The Camden Citywide Diabetes Collaborative is be a multi-pronged effort to improve diabetes care at the patient, practice and community level.
Progress
Preliminary data suggest significant reduction in hospital and emergency department overutilization for those enrolled in the program. The Camden Health Database, an aggregate of eight years of patient health care utilization and cost data from Camden’s three major hospitals, helped stakeholders to identify a crucial subset: 20% of all patients who were responsible for 90% of total costs.
Thirteen cohorts have completed the Diabetes Self-Management Education (DSME) program developed by the CCDC, three CCDC participating practices have initiated diabetes registries and six practices have implemented user-friendly electronic health records (EHR) systems.
Affiliated Sites:
Camden Coalition of Health Care Providers
For more information on the Camden Coalition, please contact Nadia Ali at nadia@camdenhealth.org.