camden citywide diabetes collaborative
DESCRIPTION
Aligning to Improve Outcomes: The Alliance to Reduce Disparities in DiabetesA presentation from a symposium at the Centers for Disease Control and Prevention’s (CDC) Division of Diabetes Translation's (DDT) 34th annual Diabetes Translation Conference on April 11-14, 2011 in Minneapolis, Minnesota.TRANSCRIPT
www.alliancefordiabetes.org
Merck Alliance to Reduce Disparities in Diabetes Camden, NJ
Camden, NJ
Project Focus:
Care management of complex patients w/ diabetes
Diabetes Self Management Education (DSME)
Practice Transformation based on PCHH
Health Information Technology (HIT)
Evolution into an Accountable Care Organization (ACO)
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ED/Hospital Referrals
13 Primary Care Practices
Citywide Care
Management
Committee
Local Care Management Team
• Nurse practitioner
• Social work case manager
• Community health worker/MA
•Program manager
Patient-Family Centered
Outreach/Care and
Practice Transformation
Health Database
Camden Citywide Diabetes Collaborative Camden Citywide Diabetes Collaborative
Transforming Primary Care ◦ Improve the capacity of primary care practices (PCP) in
Camden to provide comprehensive, proactive care to their patients with DM
◦ Transition PCP to Patient-Centered Healthcare Homes ◦ Increase number of ADA Education sites
◦ Citywide DSME referral form
◦ Implement a patient registry, EHR, group DM visits, open
access scheduling, on-site nutrition/DM education, Teachable Moments
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Transforming Primary Care (cont’d) ◦ Utilize community outreach staff to provide self-
management support to patients
◦ Conduct peer-to-peer learning and PI
◦ Professional Education Opportunities with CEs
◦ Coaching, support, and consultations to the PCP
◦ Assist practices with collecting, utilizing, and reporting quality patient data
◦ Helped to pass legislation in NJ for ACO model of healthcare delivery
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System allows Camden healthcare providers to access patient health information in real time
Initiated April 2009- ‘Go Live’ was Nov 2010
Provides labs, radiology reports, and discharge summaries from Cooper, Lourdes, and Virtua Hospitals, LabCorp, and Quest Diagnostics for patients living in Camden
$50,000 in direct contributions from the 3 Camden hospitals
$900,000 in Federal funds
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Potential Impact on Diabetes Care ◦ Most current DM data for optimal care coordination
◦ Data matching between practices and hospital data (health database, HIE)
◦ Collection of health outcome metrics used for practice quality improvement
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An integrated care delivery organization, in a defined geographic region, involving multiple primary care offices and least one hospital
◦ Provide care management to high needs patients ◦ Collaboration with healthcare and social service providers ◦ Relationships with PCPs with capacity building ◦ Manage hospitalization/specialty care
Improved health outcomes result in health care cost savings w/ gainsharing
Portion of gains return to practices to enhance practice/heathcare
Similar to Kaiser, Geisinger, and the Mayo clinic models
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Statewide Progress ◦ Greater Newark Healthcare Coalition incorporated, Trenton close
◦ White paper published
◦ Four pro-bono healthcare attorneys drafted legislation
◦ Lobbyist hired by NJ Chamber of Commerce
◦ Passed by assembly in early 2011
◦ Statewide ACO conference in January 2011
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◦ Thank you
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