Bending the Cost Curve and Improving Quality in One of America’s Poorest

Cities

Jeffrey Brenner, MD Executive Director/Medical Director

Long-term Federal Debt!

7/20/12 3

7/20/12 4

7/20/12 6

History of CCHP"!

You are cordially invited to the first

Camden City Healthcare Providers’ Breakfast

Join fellow clinicians to get acquainted, and to share strategies, resources, and ideas on providing health care to Camden City residents.

Thursday, January 24, 2002 7:30 – 9:00 am

At the Rutgers University Octagon Room, Camden Campus Center, North Third Street

Sponsored by the Center for Strategic Urban Community Leadership at Rutgers University, Division of Urban Health in the Department of Family

Medicine at Cooper Hospital, and the Camden Area Health Education Center

Please RSVP to Daria Chacón at 856-963-2432 x218 by Friday, January 11.

Camden Health Data!n  2002 – 2011 with Lourdes, Cooper, Virtua data!

n  500,000+ records with 98,000 patients!n  50 % population use ER/hospital in one year!

n  Leading ED/hospital utilizers citywide!n  324 visits in 5 years!n  113 visits in 1 year!

n  Total revenue to hospitals for Camden residents $100 million per year!n  Most expensive patient $3.5 million!n  30% costs = 1% patients!n  80% costs = 13% patients!n  90% costs = 20% patients!

Top 10 ER Diagnosis 2002-2007 (317,791 visits)!

465.9 ACUTE UPPER RESPIRATORY INFECTION (head cold)

12,549

382.9 OTITIS MEDIA NOS (ear infx) 7,638 079.99 VIRAL INFECTION NOS 7,577 462 ACUTE PHARYNGITIS (sore throat) 6,195 493.92 ASTHMA NOS W/ EXACER 5,393 558.9 NONINF GASTROENTERI (stomach virus) 5,037 789.09 ABDOMINAL PAIN-SITE NEC 4,773 780.6 FEVER 4,219 786.59 CHEST PAIN NEC 3,711 784.0 HEADACHE 3,248

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Garland

Prentiss

Old Town

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Newport

Webster

Woodville

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Burlington

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Howland

Hampden

Greenbush

Edinburg

Charleston

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Plymouth

GlenburnOrono

Newburgh

Twombly Ridge

Orrington

Kingman

Mount Chase

Eddington

Mattawamkeag

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Medway

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MaineCare Hotspot Analysis: Penobscot County7/1/2008 - 6/30/2010

A hot spot is any geography where a large number of high utilizers reside. High Utilizers are de!ned as any individual with 3 or more hospital admissions or 6 or more ER visits within 2 years. Hot spots range from blue (no hot spot) to red (intense hot spot)

What is a hot spot?

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High utilizer densityHigh

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Manchester

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MaineCare Hot Spot Analysis: Kennebec County7/1/2008 - 6/30/2010

A hot spot is any geography where a large number of high utilizers reside. High Utilizers are de!ned as any individual with 3 or more hospital admissions or 6 or more ER visits within 2 years. Hot spots range from blue (no hot spot) to red (intense hot spot)

What is a hot spot?

Low

High utilizer densityHigh

Overview of the Coalition!-  20 member board, incorporated non-profit!-  Foundation and hospital support!-  Structure of the Coalition:!

-  Operations!-  Health Information Exchange!-  Research/Data/Evaluation!-  Finance/Admin/Legal!

-  Programming!-  Citywide Care Management Project!-  Camden Chronic Disease/Primary Care Collaborative!-  Community-based Patient Engagement Strategies!

CCHP Outreach!

Hospital Admission

s Data!

•  Nurse  driven  care  transi.on  •  Pa.ents  with  history  of  ED  visits/hospital  admissions  

and  readmissions  (2+  admits  w/in  6  mos.);  socially  stable  

•  Average  6-­‐8  week  engagement  

•  Mul.disciplinary  care  management  outreach  •  Pa.ents  with  history  of  ED  visits/hospital  admissions  

and  readmissions  (4  admits  w/in  6  mos.);  social  complexi.es  

•  Average  6-­‐8  month  engagement  

Intermediate  Risk  

High  Risk   Care  Coordina.on  

Data  driven  care  mgt.  

Pa.ent  Engagement  

Medical Home!

Health  Coaching  

Inclusion!Triage!

Care Continuum Model!

ED visits, 2011

Inpatient visits, 2011

0 1 2 3 to 4 5+

0 0 1,293 57 4 1

1 26,128 2,075 117 7 0

2 to 3 13,390 1,842 373 68 3

4 to 5 3,216 666 223 118 15

6 to 7 1,020 251 106 84 24

8 to 9 386 112 39 41 11

10 + 339 96 70 65 62

Utilization typology

ED visits, 2011

Inpatient visits, 2011

0 1 2 3 to 4 5+

0

Normal Range of Utilization

Potential High Utilizers

Inpatient High Utilizers

1

2 to 3

4 to 5

Emergency Department

High Utilizers

Potential High Utilizers

6 to 7

8 to 9

10 +

Utilization typology

ED visits, 2011

Inpatient visits, 2011

0 1 2 3 to 4 5+

0 44,728 (85%) patients 5,210 Inpatient visits

63,489 ED visits

$28,000,000 (50%) IP payment $25,800,000 (59%) ED payment 985 (2%) patients

1,856 IP visits 4,129 ED visits

$10,000,000 (17%) IP

payment $1,700,000 (4%) ED

payments

503 (1%) patients 2,026 Inpatient Visits

4,144 ED Visits

$10,900,000 (20%) in IP payment $1,700,000 (4%)in ED payment

1

2 to 3

4 to 5

4,961(9%) patients 28,447 ED visits

$11,500,000 (27%) in

ED payment

1,563 (3%) patients 1,239 IP visits

6,962 ED visits

$6,700,000 (18%) in IP payment

$2,800,000 (6%) in ED payment

6 to 7

8 to 9

10 +

Utilization matrix

Es.mated  2011  Payment  ED:  $38,000  to  $76,000  (93  visits)    IP:  $65,000  to  $130,000  (12  visits)  Total:    $103,000  to  $206,000    Saving  Es.mates  30%  reduc.on  in  u.liza.on  :  ED:  -­‐28;  -­‐$11,000    to  -­‐$22,000  IP:  -­‐  4;        -­‐$19,000    to  -­‐$38,000  

Patient A

Train local residents to participate in decision-

making over health care resources!

Promote collaboration among providers and

between providers and the community!

Emergency Department High Utilizers Top 1% 2007 Camden Patients 386 Visits 5169 Visits/Patient 13.4 % visiting more than one hospital 80.6%

Trenton Patients 504 Visits 7616 Visits/Patient 15.1 % visiting more than one hospital 78.2%

Newark Patients 928 Visits 14367 Visits/Patient 15.5 % visiting more than one hospital 71.1%

Comparing Emergency Room High Utilizers in Camden, Trenton, and Newark!

SENATE, No. 2443

STATE OF NEW JERSEY 214th LEGISLATURE

INTRODUCED DECEMBER 6, 2010

Sponsored by: Senator JOSEPH F. VITALE District 19 (Middlesex) SYNOPSIS Establishes Medicaid Accountable Care Organization Demonstration Project in DHS. CURRENT VERSION OF TEXT As introduced.

The  Plan:  Compe1ng  ACOs  

Cooper  ACO  

Lourdes  ACO  

Virtua  ACO  

A  Different  ACO  Model  for  Camden  

Camden cost savings strategies!

1.  Nurse practitioner led clinics in high cost buildings!

2.  More high utilizer outreach teams!3.  Medical home-based nurse care

coordination!4.  More same day appointments (open

access scheduling)!

Lessons from Camden!

n  Strategic ability to filter, focus, and segment!n  Comfort with ambiguity and willingness to

tinker!n  Adaptive challenge not a technical challenge!n  Passion for moving towards standardization

and efficiency when the time is right!n  Meaningful solutions are local, gradual, and

require chunking!