Skip Navigation
Service Delivery Innovation Profile

Provider Team Offers Services and Referrals to Frequent Emergency Department Users in Inner City, Leading to Anecdotal Reports of Lower Utilization


Tab for The Profile
Comments
(4)
   

Snapshot

Summary

The Camden Coalition of Healthcare Providers assembles multidisciplinary outreach team to provide care management to the highest users of Camden emergency departments and hospitals. This team includes a nurse practitioner, a bilingual medical assistant, and a social work case manager, who conduct visits to homes, housing shelters, and even the streets to coordinate care in a patient-centered approach. The project provides transitional primary care, helps patients apply for Medicaid or other government-sponsored benefits programs, coordinates specialty care, coordinates transportation, helps patients access medical day programs and other social services, and provides emotional support. Feedback from team members suggests that the program has had a significant impact on emergency department use for roughly one-half of clients served and a moderate impact for another 25 percent of cases; a more formal evaluation of the program is under way. Initial evaluation after a year of activity shows that patient use of emergency departments and hospitals decrease significantly. Health systems also experienced decreased costs for these high-using patients.

Evidence Rating (What is this?)

Moderate: The evidence consists of anecdotal reports from care management team members of reduced ED use by program participants as well as initial evaluative results for 1 year of program activity.
begin doxml

Developing Organizations

Camden Coalition of Healthcare Providers
Camden, NJend do

Use By Other Organizations

In February 2009, the project began coordinating with the Camden Citywide Diabetes Collaborative to provide care management to high-using patients with diabetes.

Date First Implemented

2007
begin pp

Patient Population

Vulnerable Populations > Impoverished; Medically or socially complex; Urban populationsend pp

Problem Addressed

Inappropriate use of the emergency department (ED) is a problem in urban areas across the country, leading to overcrowding and high costs. ED "super users" account for a disproportionate share of visits, often presenting with nonurgent care needs as well as a myriad of psychosocial needs that often cannot be addressed by ED staff. However, because these individuals typically face a multitude of barriers in accessing other providers, the ED becomes their provider of choice.
  • High ED use, dominated by a few users: In 2003 in Camden, NJ, ED use was 55 percent (approximately 38,000 city residents visited the ED 68,000 times), far exceeding the national rate of 25 percent.1 An analysis of three Camden hospitals found that between 2002 and 2007, the top 1 percent of ED users (approximately 1,000 individuals) accounted for 10 percent of ED visits. Many of these ED super users had at least one psychosocial problem, such as acute psychosis, illiteracy, homelessness, alcohol dependency, drug dependency, and/or depression.2
  • Visits often for nonurgent needs: Many ED visits for these patients were for nonurgent conditions, including acute upper respiratory infections, viral infections, otitis media, and acute pharyngitis—conditions that can be treated in the primary care setting.2

What They Did

Back to Top

Description of the Innovative Activity

The Camden Coalition of Healthcare Providers assembled a multidisciplinary outreach team to provide care management to the highest users of Camden EDs and hospitals. This team includes a nurse practitioner, a bilingual medical assistant, and a social work case manager, who conduct visits to homes, housing shelters, and even the streets to coordinate care in a patient-centered approach. The project provides transitional primary care, helps patients apply for Medicaid or other government sponsored benefits programs, coordinates specialty care, coordinates transportation, helps patients access medical day programs and other social services, and provides emotional support. Key elements of the program include the following:
  • Identifying high ED users: Clinicians working in the EDs of the three Camden hospitals refer high users, typically complex patients with multiple medical and psychosocial needs, to the Camden Coalition's care management program. The referring clinician also obtains verbal consent from the patient for contact by the coalition. Reasons for the referral typically include mental illness, chronic illness, alcohol and drug abuse, physical disability, and/or pain. Social issues that create barriers to care include illiteracy, language barriers, homelessness, and/or lack of transportation. Patients are often covered by Medicaid or may be eligible for benefits but have not applied for them.
  • Locating the individuals: Patients are referred to the project by ED and inpatient physicians and social workers. After referral (and receipt of verbal consent to be contacted from the referred individual), the Care Management team makes the initial outreach to the patient to discuss the terms and objectives of the project; this occurs over the phone, at the patient's home, in the temporary shelter, on the street, or at the bedside if the patient has been admitted. A signed consent to share health information will be obtained if the patient agrees to participate in the project.
  • Services offered: The team assesses the individual's needs, provides immediate treatment when possible, and refers them to appropriate agencies for additional services as appropriate. The purpose of these interactions is both to improve the health of the patients and to teach them to seek services from appropriate locations rather than the ED.
    • Nurse practitioner role: The nurse practitioner primarily provides at-home or in-shelter transitional primary care, which entails monitoring chronic conditions, oversight of medication/prescribing, and communicating with other providers regarding the patient's care. High users lack self-management and do not respond to structured environments; the nurse practitioner can slowly transition these clients to traditional primary care access.
    • Social worker services: The social worker coordinates intense case management of the patient's care. This includes short-term needs, such as temporary housing, feeding sites, coordinating transitional care, and medical transport. The social worker also helps determine Medicaid/care eligibility or level of coverage; if the patient is not enrolled, the social worker will help with the application process. The social worker also helps the patient access social/health services, such as enrollment in a medical day program, applying for nursing home care, and accessing specialty care. In addition, the social worker assists patients apply for Supplemental Security Income, disability, or other government benefits programs.
    • Community health worker role: The community health worker is a bilingual outreach worker who works directly with the social work manager in helping patients access appropriate health/social services. The community health worker can help patients make specialty appointments, coordinate medical transportation, and accompany non–English-speaking patients to appointments.
  • Other coalition activities: The coalition engages in other activities designed to improve the health status of frequent ED users through better service delivery and greater collaboration and data sharing among providers. These activities include the following:
    • Primary care capacity building: Recognizing that many ED super users need a medical home, the coalition is sponsoring a consultant who is working with two Camden medical practices to transform them into National Committee for Quality Assurance–certified medical homes. The coalition also sponsors monthly meetings and lectures for primary care physicians and office managers to facilitate networking and support. At times, meetings offer a case presentation of an anonymous ED super user to illustrate the types of referrals that are appropriate for the program.
    • Web portal for provider communication: The coalition developed a Web portal to facilitate collaboration and communication among physicians. The portal includes a "quick fax" service, a medical and social service form repository, a pharmacy directory, a social services directory, and a provider-to-provider communication function to encourage dialogue among clinicians.

Context of the Innovation

Camden, a small city located in southern New Jersey, has a population of 79,000. U.S. Census data from 2005 reveal Camden to be the poorest city in the United States, with 44 percent of families living below the Federal poverty level. Between 25 and 30 percent of Camden residents have a chronic disease, such as diabetes, asthma, or congestive heart failure. Dr. Jeffrey Brenner, a family physician at the Robert Wood Johnson Medical School's University of Medicine and Dentistry, conducted the aforementioned study of ED visit patterns at the city's three hospitals—Our Lady of Lourdes Medical Center, Virtua Health Camden, and Cooper University Hospital. His findings showed that a few high users were responsible for a disproportionate share of ED visits and costs. Realizing that many resources could be saved if the needs of these patients could be addressed in a setting other than the ED, Dr. Brenner developed a care management program that combined medical care and social service referrals through the creation of the Camden Coalition of Healthcare Providers.

Did It Work?

Back to Top

Results

Anecdotal evidence from care management team members suggests that the program has had a significant impact on ED use. Team members estimate that they have dramatically changed the ED-seeking behavior of approximately one-half of the 65 individuals enrolled in the program since its inception in September 2007. For these individuals, team members believe that ED use has dropped substantially because of the team's redirecting them to more appropriate services. In another 25 percent of cases, team members estimate that they have helped individuals reduce ED use to a moderate degree.

Evaluation after 1 year of activity:
  • Patient use of EDs and hospitals decreased by 40 percent after enrolling with the project.
  • Health systems charges for the care of these high-using patients was reduced by 56 percent (receipt is reduced by 39 percent).
  • Reimbursement increased by 51 percent due to ability of health systems to retroactively bill for services after a patient has been approved for disability benefits.

Evidence Rating (What is this?)

Moderate: The evidence consists of anecdotal reports from care management team members of reduced ED use by program participants as well as initial evaluative results for 1 year of program activity.

How They Did It

Back to Top

Planning and Development Process

Key elements of the planning and development process included the following:
  • Creating ED use database: Researchers spent 3 years creating a citywide health database using claims data from the three local hospitals. This process required gaining the approval of each hospital's institutional review board, collecting the data, and building the database. This database was used as the basis of the aforementioned study, which found that relatively few ED users  accounted for a disproportionate number of visits.
  • Formalizing the organization: The developer of the program received a planning grant from the Robert Wood Johnson Foundation to create the Camden Coalition. Grant funding was used to create a board of hospital leaders and primary care physicians, develop bylaws, undertake more sophisticated data analysis, and fund a part-time administrator.
  • Developing services and hiring the team: As data collection efforts increased and analyses confirmed the extent of ED overuse, the coalition built a Web portal and hired the care management team.
  • Building the coalition: The developer hired a practice management consulting firm to run primary care conferences and other events and visit primary care offices in the city to draw them into the coalition's activities. Coalition-building efforts also included monthly citywide meetings with social workers and physicians to discuss high ED users and anonymous case presentations and to solicit program referrals.

Resources Used and Skills Needed

  • Staffing: Camden Coalition has a full-time social worker, community health worker, and nurse practitioner, along with a part-time family physician and program administrator. The three-person care management team currently has 65 clients but could likely handle as many as 150 cases.
  • Costs: Annual operating costs are approximately $385,000, consisting primarily of staff salaries and benefits.
begin fsxml

Funding Sources

Robert Wood Johnson Foundation; Centene Foundation
The Robert Wood Johnson Foundation provided a $50,000 planning grant, along with a subsequent 3-year grant of $300,000. The Centene Foundation (which is operated by a New Jersey Medicaid health maintenance organization) provided a $30,000 grant. Other funding comes from the Connelly Foundation, the Merck Company Foundation, and Camden-area hospitals.end fs

Tools and Other Resources

An interview about the Camden Coalition between the innovator and New Yorker writer, Atul Gawande, is available at http://www.pbs.org/wgbh/pages/frontline/doctor-hotspot/.

Adoption Considerations

Back to Top

Getting Started with This Innovation

  • Build hospital administrator support: Develop relationships with administrators at various hospitals who can help make the case to the institutional review boards that data requests should be approved.
  • Build a database of patient utilization: Hard data can help make the case that initiatives to reduce ED use are worthy of financial and in-kind support.
  • Organize the community: Patiently build relationships among hospitals, social service agencies, and primary care offices so that they will become accustomed to working together on community health issues.
  • Develop a medical and social model of care: Complex patients who are high users of the ED typically have a myriad of both medical and psychosocial problems. Social issues, such as the need for transportation and translation services, can constitute meaningful barriers to medical care that must be overcome if health improvements are to be achieved.

Use By Other Organizations

In February 2009, the project began coordinating with the Camden Citywide Diabetes Collaborative to provide care management to high-using patients with diabetes.

More Information

Back to Top

Contact the Innovator

Jeffrey Brenner, MD
Medical Director, Urban Health Institute at Cooper University Healthcare
Executive Director, Camden Coalition of Healthcare Providers
800 Cooper Street, 7th Floor
Camden, NJ 08102
Phone: (609) 876-9549
E-mail: jeff@camdenhealth.org
http://www.camdenhealth.org

Innovator Disclosures

Dr. Brenner has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

http://www.camdenhealth.org

Footnotes

1 Camden Coalition of Healthcare Providers. Available at: http://www.camdenhealth.org/index/ccmp.cfm
2 Camden Coalition of Healthcare Providers. Materials provided by innovator.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: November 10, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 04, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: December 22, 2009.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.