Camden Coalition of Healthcare Providers
Studies by the Agency for Healthcare Research and Quality have shown that the sickest 5 percent of U.S. patients account for over half of the country's health care costs. These "high utilizers" often suffer from multiple chronic conditions and take many medications. The Camden Coalition of Healthcare Providers (CCHP) provides a model for effective, efficient care for the highest utilizers in the community it serves, improving the health of the community while reducing the cost of care. The CCHP has accomplished this by identifying high utilizers through analyzing local claims data and providing them with well-coordinated care through a personalized care management system. By combining typical health care services such as primary care and chronic care management with social support and behavioral health interventions, the CCHP addresses the full spectrum of factors that influence health.
Summary of Activities:
Each day, the CCHP receives a feed from the local health information exchange with a list of the patients from all three of Camden's health systems who have been admitted three or more times in the past 6 months. The CCHP's staff triages the list, focusing on patients taking multiple medications and with language or social barriers. Nurses then visit the patients in the hospital to start the conversation about the health issues these patients have been facing. They then invite the patient to enroll in the home visiting program. If the patient accepts, the home-visiting intervention is deployed.
The first visit at the home occurs within 3 days of the person's discharge from the hospital. The goal is to help the person receive a primary care appointment within a week. The CCHP health team accompanies the individual to the primary care appointment to help build or rebuild his or her relationship with the primary care provider. After that, the CCHP health team follows up with weekly home visits with a personalized set of staff members based on the patient's needs,including family physicians, nurse practitioners, medical assistants, or social workers. The ultimate goal is to graduate socially and medically stable individuals who are connected to their primary care provider within 3 months.
This intervention has been successful in reducing the health care costs by half and hospitalizations by 40 percent for the individuals it serves. The Robert Wood Johnson Foundation expanded the model into six different Aligning Forces for Quality communities in 2012 to evaluate whether the results in Camden could be replicated across the nation.
Alignment to the National Quality Strategy (NQS):
These efforts promote:
- Effective communication and coordination of care.
- Working with communities to promote wide use of best practices to enable healthy living.
- Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.
The Board of Directors that governs CCHP includes three hospital systems, two Federally Qualified Health Centers, independent provider offices, social service and behavioral health organizations, and resident advocacy organizations. Learn more about the Camden Coalition of Healthcare Providers.