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Camden Coalition of

Healthcare Providers
Camden Citywide Diabetes
Innovation in reaching those at highest risk
through information exchange across
community care delivery systems

Merck Alliance to Reduce Disparities in


Camden, NJ
Camden, NJ
 Project Focus:

 Care management of complex patients w/

 Diabetes Self Management Education (DSME)
 Practice Transformation based on PCHH
 Health Information Technology (HIT)
 Evolution into an Accountable Care Organization

Citywide Care Management
ED/Hospital Referrals
13 Primary Care Practices

Local Care Management Team

•Nurse practitioner Citywide Care
Health Database •Social work case manager Management
•Community health worker/MA Committee
•Program manager

Camden Citywide
Citywide Diabetes
Diabetes Collaborative

Patient-Family Centered
Outreach/Care and
Practice Transformation
 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

 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

Camden Health Information Exchange (CHIE)
 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

 $900,000 in Federal funds

Camden Health Information Exchange (CHIE)
 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

Accountable Care Organizations (ACOs)
Ø 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
◦ Relationships with PCPs with capacity building
◦ Manage hospitalization/specialty care
Ø Improved health outcomes result in health care cost
savings w/ gainsharing
Ø Portion of gains return to practices to enhance
Ø Similar to Kaiser, Geisinger, and the Mayo clinic models

Accountable Care Organizations (ACOs)
 Statewide Progress
◦ Greater Newark Healthcare Coalition incorporated, Trenton
◦ 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


 Thank you