1. 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

2. 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.

3. 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.

4. 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.

6. 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

8. 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

10. 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

11. 16+ emergency department visits
7+ police encounters

12. Prevalence of socio-behavioral complications

14. 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

15. 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)