Alliance to Reduce Disparities in Diabetes

Featured Project Effort

Transforming Health Care Delivery for Chronically-ill Patients in Camden

The Camden Coalition of Health Care Providers, one of the five Alliance grantees, is transforming their health care delivery system by reaching out to the most vulnerable, chronically-ill patients in their community who are also the most frequent users of hospitals and emergency rooms. The idea is that by providing focused and ongoing patient education, outreach and care management to these patients, they will be able to drastically reduce hospitalizations and improper emergency room utilization, and save money.

The Camden Coalition has just signed an agreement with a New Jersey Medicaid HMO to create a new accountable care organization (ACO) in Camden. The contract uses the policy framework created by recently passed legislation in the state of New Jersey. This legislation, signed by the governor in August, provides pilot funding for the creation of Medicaid ACOs and allows organizations like the Camden Coalition to design their own Medicaid health care programs for high-users of health care services. Through this new contract, the Camden Coalition will create a diverse local care management team to identify high-users and arrange and organize care for these patients. The Coalition will use an integrated approach that includes outreach, transitional primary care, and coordination of behavioral health, social services, home health and health education. It is estimated that this approach could result in significant Medicaid cost savings by reducing hospital visits. Under this new agreement, the New Jersey Medicaid HMO would share a portion of the cost savings with the Camden Coalition and its member practices.

“If we manage to bend the cost curve and improve quality at the community level, the Coalition will capture a portion of those savings for reinvestment and this creates a mechanism for financial stability,” said Dr. Jeffrey Brenner who has been leading the effort for the Camden Coalition. This agreement expands the work Brenner has been doing over the last nine years.

In Camden, about 50 percent of the residents visit a hospital or emergency room within a 1-year period. This is twice the national average. Many of these chronically-ill people are hospitalized several times every year. In fact, it was reported that just 20% of the hospital patients in the city of Camden were responsible for nearly 90% of the total costs.