Improving Diabetes Outcomes for High-Utilizing Patients in Camden

ABSTRACT

Goals: The Camden Coalition of Healthcare Providers’ (CCHP) ultimate aim is the reduction of health care costs through improved care coordination. It targets patients with these specific goals:

1) Identify patients suitable for enrollment through the Camden Health Informaiton Exchange (HIE)2) Use of a Care Transitions outreach team for home assessment and effective transition from the hospital3) Improve clinical outcomes and process measures such as attendance to DSME classes and improved adherence to primary care visits4) Decreased rates of ER and hospital use

Method: Patients with excess ER and inpatient hospital admissions were identified for the program through the Camden Health Information Exchange (HIE). Patients who meet the criteria are enrolled at bedside for a 30-90 day intensive care coordination intervention.

Target Population: Camden City residents with at least two ER visits or hospital admissions within 6 months and chronic co-morbidities.

Outcome Measures: Measuring clinical outcomes such as: HbA1c, lipids and blood pres-sure; number of patients attending DSME; reduction in the number of preventable hospitalizations.

Evaluation Results: In a six year period (2002-2008), a total of 7,041 patients with diabetes utilized area ER and hospitals for a total of 62,560 visits. Charges totaled $1,550,429,036.37 with re-ceipts of $203,716,769.83. Among several patients, there was a dramatic decline of ER and hospital utili-zation from pre-enrollment to post-enrollment, some without any utilization.

Preliminary analysis shows that of the 25 patients enrolled in the Care Transitions program, approximately 25% have diabetes as a comorbidity. For n=21 patients, there was a 57% decrease in both ER and ospi-tal utilization post-enrollment. For ER utilizations, there was an average of $925 per month of charges before enrollment and $0 per month after enrollment while for in-patient admissions, there was an aver-age of $22,225 per month of charges before enrollment and $0 per month after enrollment in the pro-gram.

INTERVENTION RESULTS

FACILITATING/HINDERING FACTORS

TARGET POPULATION

Data from a Camden City Comprehensive Health Database (July 2002 - June 2008)

17.0% 08102

15.6% 08103

12.7% 08105

11.6% 08104

percent of population with at least 1 visit Visits by Diabetics by ZIP

Visits by Diabetics by Hospital

Cooper 31,814

OLOL 22,897

Virtua 7,849

11.6% - 12.7%

15.6%

17.0%

E.D. Visits

Inpatient Visits % Inpatient

Diabetes 39,946 22,610 57%

Overall 386,093 79,088 20%

Visits Patients Visits / Patient

Diabetes 62,560 7,041 8.89

Overall 465,203 103,706 4.49

Number of Visits

Total Visits

Total Patients Charges

1 to 10 22,075 5,270 $674,344,336.42

11 to 20 16,134 1,126 $431,920,873.45

Over 20 24,351 645 $444,163,826.50

Receipts

$92,597,330.57

$55,148,779.38

$55,970,659.88

TOTAL 62,560 7,041 $1,550,429,036.37 $203,716,769.83

Facilitating Factors:• Longitudinal relationship based on rapport and trust between patients and outreach team• Having a proactive holistic model of care that is focused on respect and non-judgment• Strong relationship and support from community partnerships• Community-based problem-solving

Hindering Factors:• Patient barriers such as language, insurance, readiness for behavior change, and food security• Scheduling follow-up appointments within one week with primary care• Tracking down at-risk patients

Transitions of Care Guiding Principles:• Enroll patients based on data: history of repeat admissions (high cost) and specific inclusion criteria• Provide immediate and intensive follow-up coordination post-discharge; connect patient to PCP as quickly as possible (target = 7 days post-discharge)• Dramatically improve the relationship between patient and PCP• Equal focus of intervention on health coaching

Outreach Team Composition:

High Risk Outreach Team Intermediate Risk Outreach TeamRN RNMA LPNSocial Worker Health CoachesHealth Coaches

Patient Selection:• History of 2+ admissions within past 6 months• History of chronic disease related admits• Socially stable• Rule-out criteria o Oncology o Pregnancy o Acute Trauma o Psych only diagnosis o Surgical Operation

Division of Work (0-30 days post)

Nursing Health CoachesClinical assessment Make appointmentsMedication reconciliation Transportation enrollment &

trainingEstablish care plan; identify patient goals

Nutritional support AND food security

Accompanied PCP and specialty care follow up appointments

Mobility assistance

Follow-up home visits; care provider reinforcement

Accompaniment

Establish Health Coach plan for second phase

Division of Work (30-90 days post)

Nursing Health CoachesMedication reconciliation Logistics: make own

appointments, arrange own transportation, access specialty care

Chronic disease maintenance Disease self management: awareness of chronic disease maintenance, can communicate with provider(s) and navigate an agenda

Handle readmissions Social skills: can find resources, life management skills

Schedule hand-off appointment;graduation to PCP

Ongoing social support

Care Transitions time-line and workflow.

Patients are identified as candidates for the program through a daily feed from the Health Information Exchange.

INTRODUCTION

Preliminary Analysis:

• 25% of patients (n=21) enrolled in Care Transitions have diabetes as a co-morbidity

• There was a 57% decrease in both ER and hospital utilization post-enrollment across all patients

• ER utilizations decreased from an average of $925/month of charges to $0 per month after enrollment

• In-patient admissions decreased from an average of $22,225 per month of charges to $0 per month after enrollment

Patient Utilization EKG*

*Utilization EKG’s are used to graphically represent patient ER and in-patient hospital utilization and cost for individual patients. This example shows a diabetic patient whose utilization fell to zero after being enrolled in the Care Transitions program.

The Care Transitions Program has been successful in reducing both ER visits and in-patient hospitalizations. This has been accomplished by strong team dynamic, benchmarking progress, standardizing discharge plans, and quick and intense follow-up post-discharge. Our success also underscores the importance of a trusting healing relationship between provider and patient and the ability to coordinate across a number of public services and medical offices.

CONCLUSIONCCHP is a nine-year old strategic initiative with a mission to improve the quality, capacity, and ac-cessibility of the healthcare system for vulnerable populations in Camden, NJ. In 2011 the Care Transitions Program, borne out of the Care Management Project, was created. It is a 30-90 day intervention targeting high cost, medically complex patients. These patients lack consistent primary care; often suffer from chronic co-morbidities, including diabetes. This is a report on the process and current outcomes of the Care Transition outreach teams (consisting of a Registered Nurse, Licensed Professional Nurse and AmeriCorps health coaches) and their impact on the healthcare delivery in Camden.

Steven Kaufman MD; Nadia Ali MPA; Victoria DeFiglio RN, BSN; Jason Turi RN, MPH; Maechiel Lluz