1. The Camden Coalition of Healthcare Providers Jeffrey Brenner, MD Dept of Family Medicine Robert Wood Johnson Medical School Camden, NJ

2. Local Camden Challenges Insights from the Camden Health Dataset and Census Data

3. Camden City Demographic Information Population 1990- 87,492 Population 1990- 87,492 Population 2000- 79,904 decrease 8.7% Population 2000- 79,904 decrease 8.7% Source: Camconnect Camden Facts

4. Camden City Demographic Information 2000 Age Distribution Source: Camconnect Camden Facts

5. Camden City Demographic Information Source: US Census

6. Very Challenging Healthcare Environment High rates of violence High rates of violence Failing education system Failing education system School system, Police department, City government in State takeover School system, Police department, City government in State takeover Significant rate of home abandonment Significant rate of home abandonment Ethnically diverse with high rate of non-English speaking residents Ethnically diverse with high rate of non-English speaking residents No history of cooperation between local healthcare stakeholders No history of cooperation between local healthcare stakeholders

7. Results from Camden Health Database

8. Camden Health Data Overview 2003: Overview 2003: 68,000 Visits 68,000 Visits 38,000 Unique patients across institutions 38,000 Unique patients across institutions Used rough methodology of DOB and part of address Used rough methodology of DOB and part of address Approx 50% of the City population uses the ER/hospital in one year Approx 50% of the City population uses the ER/hospital in one year Significant geographic variations Significant geographic variations

11. Source: Camconnect Camden Health Report, 2006

12. Camden Health Data New Data Set 2002 - 2007 New Data Set 2002 - 2007 387,000 records with 98,000 patients 387,000 records with 98,000 patients Leading utilizer came 324 visits Leading utilizer came 324 visits 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

13. Top 10 ED Diagnosis 2002-2007 (317,791 visits) 465.9ACUTE URI NOS12,549 382.9OTITIS MEDIA NOS7,638 079.99VIRAL INFECTION NOS7,577 462ACUTE PHARYNGITIS6,195 493.92ASTHMA NOS W/ EXACER5,393 558.9NONINF GASTROENTERIT NEC5,037 789.09ABDOMINAL PAIN-SITE NEC4,773 780.6FEVER4,219 786.59CHEST PAIN NEC3,711 784.0HEADACHE3,248 729.5PAIN IN LIMB2,908 724.5BACKACHE NOS2,858 789ABDOMINAL PAIN2,836 599.0URIN TRACT INFECTION NOS2,799 V58.3ATTENT DRESSING/SUTURE2,792 724.2LUMBAGO2,704 920CONTUSION FACE/SCALP/NCK2,645 490BRONCHITIS NOS2,526 V68.9ADMIN ENCOUNTER NOS2,475 786.50CHEST PAIN NOS2,455

14. Top 10 Hospital Diagnosis 2002-2007 (65,988 visits) V30.00SINGLE LB-IN HOSPITL NEC6,315 786.59CHEST PAIN NEC2,378 428.0CONGESTVE HRT FAILUR NOS2,033 V30.01SINGLE LB/BY C-SECTION1,985 486PNEUMONIA, ORGANISM NOS1,554 493.92ASTHMA NOS W/ EXACER1,210 414.01CORNARY ATHERO-NATV VESL1,038 645.11POST TERM PREG-DELIVERED994 654.21PREV C-SECT NOS-DELIVER801 491.21OBST CH BRONCH W/ EXAC738 599.0URIN TRACT INFECTION NOS673 664.01DEL W 1 DEG LACERAT-DEL649 780.2SYNCOPE AND COLLAPSE588 276.5VOLUME DEPLETION561 780.39OTHER CONVULSIONS554 650NORMAL DELIVERY549 659.71ABN FETAL HRT RATE, DEL531 410.71SUBENDO INFRC-INIT EPISD527 682.6CELLULITIS OF LEG513

15. Top 1% of Utilizers (2002- 2007) 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

16. Building a Local Healthcare Coalition The Camden Coalition of Healthcare Providers

17. Mission of the Coalition The Coalition seeks to improve the health status of Camden City residents through: collaboration collaboration data sharing data sharing education education improvements in service delivery improvements in service delivery

18. Overview of the Coalition - Started in 2002 from an informal breakfast of local providers - 20 member board, incorporated non-profit - Foundation and hospital support - 4 main projects - Primary Care Practice Capacity Building - Web Portal - Expanded access to mental health services - Citywide Care Management Project

20. Web Portal Tools Quick fax Quick fax Form repository Form repository One click log-in for insurance companies One click log-in for insurance companies Pharmacy directory Pharmacy directory Social services directory Social services directory Pre-referral specialty coordination Pre-referral specialty coordination

21. Practice Management Capacity Building Project Monthly Office Manager Meetings Monthly Office Manager Meetings Practice Management Consultations Practice Management Consultations Implemented EHR in one office Implemented EHR in one office

22. Citywide Care Management System

23. 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

24. Experience Thus Far Started Sept/Oct enrolling clients Started Sept/Oct enrolling clients 60 enrolled so far 60 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

25. Experience Thus Far Patient Challenges Patient Challenges Housing73% Housing73% Transportation/Mobility58% Transportation/Mobility58% Mental Illness30% Mental Illness30% Alcohol & Drug Abuse58% Alcohol & Drug Abuse58% Accomplishments Accomplishments Long-term Housing68% Long-term Housing68% Transitional Housing45% Transitional Housing45% Link w/ Medical Services58% Link w/ Medical Services58% Medication/Equipment66% Medication/Equipment66% Link w/ Public Assistance47% Link w/ Public Assistance47%

26. Experience Thus Far 43 patients matched in database 43 patients matched in database Range of visits 1 to 324 Range of visits 1 to 324 Most expensive patient Most expensive patient $4,973,811 charges $4,973,811 charges $661,155 receipts $661,155 receipts Average receipts $69.653 Average receipts $69.653 Visits 1,663 with average 38.67 visits/patient Visits 1,663 with average 38.67 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

27. Citywide Care Management System Case #1 Case #1 46 y/o AA male with CAD, morbid obesity, DM, severe CHF (EF 15%) 46 y/o AA male with CAD, morbid obesity, DM, severe CHF (EF 15%) 2 previous admission this year to Kennedy and Virtua 2 previous admission this year to Kennedy and Virtua Semi-homeless, lives in welfare motel with girlfriend, evicted from apartment recently Semi-homeless, lives in welfare motel with girlfriend, evicted from apartment recently Hx of substance abuse Hx of substance abuse No consistent primary care No consistent primary care

28. Citywide Care Management System Case #1 Case #1 Admitted to Cooper with dyspnea and abdominal pain, stayed 2 months Admitted to Cooper with dyspnea and abdominal pain, stayed 2 months Cholelithiasis, sepsis, intubation, PEG tube, C Diff infection, staph infection from PIC line Cholelithiasis, sepsis, intubation, PEG tube, C Diff infection, staph infection from PIC line Subacute rehabilitation discharge x 10 days Subacute rehabilitation discharge x 10 days Discharged to welfare motel Discharged to welfare motel

29. Citywide Care Management System Case #1 Case #1 Auto assigned to Medicaid HMO Auto assigned to Medicaid HMO Severe limitations in mobility Severe limitations in mobility Qualifies for federal disability benefits Qualifies for federal disability benefits Very poor flow of information across inpatient teams, to rehabilitation, and to my office Very poor flow of information across inpatient teams, to rehabilitation, and to my office

30. Citywide Care Management System Case #2 Case #2 50 y/o patient with Rheumatoid arthritis and heart failure 50 y/o patient with Rheumatoid arthritis and heart failure Admitted nearly every week to a hospital Admitted nearly every week to a hospital On long term SSI, homeless, history of drug use On long term SSI, homeless, history of drug use Admitted with GI bleed Admitted with GI bleed Refuses colonoscopy and gets into an argument with hospitalist over colonoscopy preparation Refuses colonoscopy and gets into an argument with hospitalist over colonoscopy preparation

31. Citywide Care Management System Case #2 Case #2 Discharged from hospital same day directly to homeless shelter Discharged from hospital same day directly to homeless shelter Can’t get out of cab and is readmitted to CCU at the same hospital on the same day Can’t get out of cab and is readmitted to CCU at the same hospital on the same day

32. Citywide Care Management System Themes- Themes- Housing, Housing, Housing- patients are using the hospital for medical respite Housing, Housing, Housing- patients are using the hospital for medical respite Inadequate primary care Inadequate primary care Medical transport doesn’t work Medical transport doesn’t work Very complex, co-morbid medical, psych, substance abuse, and pain management issues Very complex, co-morbid medical, psych, substance abuse, and pain management issues Pt’s eligible for additional benefits but no one has helped them apply Pt’s eligible for additional benefits but no one has helped them apply Criminal histories are a barrier to care Criminal histories are a barrier to care

33. Citywide Care Management System Themes- Themes- Pt’s are hard to find and stay in contact with Pt’s are hard to find and stay in contact with Very poor flow of information across boundaries of care Very poor flow of information across boundaries of care Pt’s are VERY VERY expensive Pt’s are VERY VERY expensive Mostly in 40’s - 50’s Mostly in 40’s - 50’s Frustrating to hospital and ED staff Frustrating to hospital and ED staff Prone to get hospital acquired infections Prone to get hospital acquired infections Don’t have SS cards and birth certificates Don’t have SS cards and birth certificates

34. Health care from a high utilizers point of view: Dial 911 for warm bed, food, and shelter

35. A New Paradigm: High utilizers are a failure of our healthcare delivery system to provide patient centered care. By building a system capable of meeting their needs, we learn lessons to build a system capable of meeting all of our needs better.

36. Next Steps: Citywide Electronic Health Records for High Utilizers 1000 Of the Sickest Patients in Camden on a Mac Mini Computer 7” x 7” x 2” Accessible by Every ED and Hospital in Camden

37. More Information www.camdenhealth.org www.camconnect.org brennejc@umdnj.edu