Alliance to Reduce Disparities in Diabetes

Camden Citywide Diabetes Collaborative

THE PROGRAM:

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 capacitybuilding, 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.

THE GOALS:

  • Improve the capacity of community-based, primary care practices to provide comprehensive, proactive care to their patients with diabetes
    • Facilitate the certifi cation of 10 community-based, primary care practices in Camden as Patient-Centered Medical Homes by the National 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

THE 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 a multi-pronged effort to improve diabetes care at the patient, practice and community level.

PROGRESS:

  • Preliminary data suggest signifi cant 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.
  • Patient engagement initiatives including youth and adult diabetes support groups, yoga, and fi tness classes have shown improvement in patient self-care behaviors and stress levels.
  • 36 cohorts have completed the Diabetes Self-Management Education (DSME) program developed by the CCDC, of which 17 were completed in Spanish, and all major electronic health records (EHR) systems will work towards adopting automatic registry building capabilities.
  • The organization has had success in achieving New Jersey Accountable Care Organization (ACO) legislation - signed by Gov. Christie, August 2011, and received national level visibility through features in The New Yorker, on NPR, Frontline (PBS), and CNN.

Affiliated Sites:

Camden Coalition of Health Care Providers

For more information on the Camden Coalition, please contact Nadia Ali at nadia@camdenhealth.org.

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