Building Patient Centered Medical Homes in America’s Poorest City-Camden, NJ Jeffrey Brenner, MD Medical Director Camden Coalition of Healthcare Providers

Objectives Review the use of a citywide health database to plan, implement, and evaluate health improvement projects in Camden, NJ. Examine current health improvement projects run by the Camden Coalition of Healthcare Providers. Describe plans for healthcare payment reform to expand projects in Camden.

Dartmouth Atlas Source: Dartmouth Atlas of Healthcare Inpatient and Part B spending per decedent during last 2 years of life #1

Source: Dartmouth Atlas

Camden Health Data New Data Set New Data Set ,000 records with 98,000 patients 480,000 records with 98,000 patients 50 % population use ER/hospital in one year 50 % population use ER/hospital in one year Leading utilizer came 324 visits/5yrs Leading utilizer came 324 visits/5yrs Most expensive patient $3.5 million Most expensive patient $3.5 million Total revenue to hospitals for Camden residents $460,000,000 + charity care Total revenue to hospitals for Camden residents $460,000,000 + charity care 80% costs = 13% patients 80% costs = 13% patients 90% costs = 20% patients 90% costs = 20% patients

Top 10 ED Diagnosis (317,791 visits) 465.9ACUTE URI NOS12, OTITIS MEDIA NOS7, VIRAL INFECTION NOS7, ACUTE PHARYNGITIS6, ASTHMA NOS W/ EXACER5, NONINF GASTROENTERIT NEC5, ABDOMINAL PAIN-SITE NEC4, FEVER4, CHEST PAIN NEC3, HEADACHE3,248

Chronic Illness In Camden

Northgate I public housing

High cost hot spots in Camden, NJ

Source: Camconnect Camden Health Report, 2006

Top 1% of Utilizers ( ) 1,035 patients with 39,056 visits 1,035 patients with 39,056 visits Between 24 and 324 visits Between 24 and 324 visits Total charges $375 million Total charges $375 million Total receipts $46 million + charity care Total receipts $46 million + charity care Enough $$ to fund 50 family physicians or 100 nurse practitioners Enough $$ to fund 50 family physicians or 100 nurse practitioners

Overview of the Coalition - 20 member board, incorporated non-profit - Foundation and hospital support - $2.5 million in grant funding - $1.5 million in hospital funding - Projects- - Camden Health Database - Citywide Care Management Project - Camden Diabetes Collaborative - Camden Health Information Exchange

Camden Health Database Camden Citywide Care Management Committee Local Care Management Team Nurse practitioner Social work case manager Community health worker Citywide Care Management System

Experience Thus Far Started Sept/Oct 2007 enrolling clients Started Sept/Oct 2007 enrolling clients 115 enrolled so far 115 enrolled so far Tremendous challenges in patient issues Tremendous challenges in patient issues Good progress in communication between stakeholders Good progress in communication between stakeholders

Case Management- Experience Thus Far Over 5 year period: Most expensive patient Most expensive patient $4,973,811 charges $4,973,811 charges $661,155 receipts $661,155 receipts Visits 1,663 with average visits/patient Visits 1,663 with average visits/patient 37% visits are inpatient 37% visits are inpatient Total 43 patients Total 43 patients $25,598,615 charges $25,598,615 charges $2,995,080 receipts $2,995,080 receipts

Preliminary Results Charges per month n Ratio of Before to AfterBeforeAfter Absolute Change Percent Change 361:1$1,218,009.69$531, $686, % Receipts per month n Ratio of Before to AfterBeforeAfter Absolute Change Percent Change 361:1$83,992.29$55, $28, % Visits per month n Ratio of Before to AfterBeforeAfter Absolute Change Percent Change 361: % Percent Reimbursment per month n Ratio of Before to AfterBeforeAfter Absolute Change Percent Change 361:16.90%10.47%3.58%51.90%

Goals Camden Diabetes Collaborative 1. Transform primary care at 10 local offices (Patient Centered Medical Home using Chronic Care Model) 2. Improve access to diabetic education 3. Care coordination with Medical Day Programs 4. Targeted care of the high cost/high needs DM patients

Diabetes In Camden

Diabetes Education Program in Local Community Center Office Participating in Diabetes Collaborative Jeff Kleeman, MD Fairview Neighborhood Analysis for Diabetes Collaborative Hospital Visits for Diabetes by Fairview Residents Receipts per Patient VisitsPatientsChargesReceiptsCollections by year $4,832,435$677,863$5, % $9,678,565$1,142,730$9, % $10,005,427$1,033,585$6, % 1/1/2002 to 6/30/2008 Cooper648217$26,518,688$3,544,053$16, % Lourdes779277$16,697,402$2,033,819$7, % Virtua3224$101,711$11,979$ % Inpatient743294$41,580,481$5,367,810$18, % Emergency715288$1,667,140$199,466$ % Total1,459449$43,317,801$5,589,852$12, %

Linking Claims Data Citywide Primary care office Citywide hospital dataset

Camden Health Information Exchange Phase 1- Ability to view labs, radiology, discharge summaries for Cooper, Lourdes, Virtua, Quest, and Labcorp Phase 1- Ability to view labs, radiology, discharge summaries for Cooper, Lourdes, Virtua, Quest, and Labcorp Phase 2- Ability to utilize lab data to build citywide registries and real-time alerts Phase 2- Ability to utilize lab data to build citywide registries and real-time alerts 1 st phase funded by hospitals and Merck grant 1 st phase funded by hospitals and Merck grant Ready Winter/Spring 2010, CIO’s are meeting regularly Ready Winter/Spring 2010, CIO’s are meeting regularly

Definition of an ACO An integrated care delivery organization, in a defined geographic region, involving multiple primary care offices and least one hospital. Relationship to specialty care. An integrated care delivery organization, in a defined geographic region, involving multiple primary care offices and least one hospital. Relationship to specialty care. The ACO needs to be capable of managing costs/utilization and improving quality. The ACO needs to be capable of managing costs/utilization and improving quality. An attempt to mimic Kaiser, Geisinger, and the Mayo clinic. An attempt to mimic Kaiser, Geisinger, and the Mayo clinic.

Payment reform Gainsharing Gainsharing Capitation payments Capitation payments Episode of care payments Episode of care payments

Capacities of an ACO Ability to link and analyze claims data Ability to link and analyze claims data Ability to provide care management to high cost/high needs patients Ability to provide care management to high cost/high needs patients Collaboration with medical and social service providers Collaboration with medical and social service providers Relationships with primary care providers with capacity building Relationships with primary care providers with capacity building Ability to manage hospitalization/specialty care Ability to manage hospitalization/specialty care

ACO Funding Model 1% Reduction2% Reduction 2008$899,881$1,799, $1,853,756$3,689, $2,864,075$5,672, $3,933,392$7,753, $5,064,361$9,934, $6,259,747$12,221, $7,522,425$14,617,166

Benefits of ACO Stable platform for rapid adoption of innovations Stable platform for rapid adoption of innovations Encourages stakeholder engagement and collaboration Encourages stakeholder engagement and collaboration No free riders amongst payers No free riders amongst payers No new contracts/negotiations necessary with payers No new contracts/negotiations necessary with payers Revenue neutral Revenue neutral Could leverage significant foundation and private capital investments Could leverage significant foundation and private capital investments

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