Healthcare Hotspotting: A Data strategy for delivering better care to individuals with complex health and social needs Criminal Justice-Behavioral Health: Partnerships Creating Integrated Healthcare San Antonio, TX January 29-31, 2017

Overview of the Camden Coalition We are a citywide coalition of hospitals, primary care providers, and community representatives that collaborate to deliver better healthcare to our most vulnerable citizens. We innovate and test health care delivery models to improve patient outcomes and reduce the cost of their care using data driven, human-centered practices.

Healthcare hotspotting is the strategic use of data to target evidence-based services to complex patients with high utilization. These patients are experiencing a mismatch between their needs and the services available.

Outlier patients in the long tail of data Healthcare hotspotting is the strategic use of data to target evidence-based services to complex patients with high utilization. These patients are experiencing a mismatch between their needs and the services available.

Camden Coalition Data Holdings Camden HIE: regional health information exchange that brings together real-time clinical data to support operations, including identifying patients for intervention TrackVia: cloud-based, HIPAA-compliant database that allows the Coalition to track intervention workflows and improve processes Camden ARISE: a longitudinal, archival integrated data system of health care, social services, and social determinants data for intervention planning, research, and evaluation

Data for Continuous intervention monitoring and quality improvement Week 1 Week 10 168 Days 38 Days Days Since Last Engagement Days To First Primary Care Visit 2013 2014 2012 Data for Continuous intervention monitoring and quality improvement Week 11 Week12 Week 13 Week 14 Week 15 Week 16 Week 17 Week 18 Week 19 Week 20 Week 21 Week 22 Week 23 Week 24 Week 25 Week 26 Week 27 Week 28 Week 29 Week 30 Week 31 H o u r s Weekly staff hours with patients

12,541 people overlap 93,344 people visiting the hospital with an arrest 226 people with dual sector high utilization (DSHU) 5 years, ever having a Camden address

16+ emergency department visits 7+ police encounters

Prevalence of socio-behavioral complications

Segmentation for intervention planning: Typical profile in each of four DSHU clusters Male, 18-29 Frequent arrests for drug possession; no violent crime arrests Dx serious behavioral health conditions Medically complex, including HIV Male, 40+ Extreme ED utilization, low admissions Public nuisance arrests, rare drug possession Housing instability and homelessness common Male, 18-29 Diverse arrest profile, including drug trafficking, property, violent crime arrests Compared to other segments, lower medical and behavioral health complexity Woman, 40+ Simple assault; infrequent drug arrests High hospital admissions, including for assault-related injuries Severe mental health challenges; suicidal ideation

Thank you for your time! Dawn Wiest Associate Director Action Research & Evaluation Camden Coalition of Healthcare Providers 800 Cooper Street, 8th floor Camden, NJ 08102 (856) 365-9520 dwiest@camdenhealth.org