Upgrading Care for Complex Patents

The Camden Coalition of Healthcare Providers (Camden Coalition) www.camdenhealth.org is establishing a national center to improve care for high-need patients who experience poor outcomes despite extreme patterns of hospitalizations or emergency care.

The Camden Coalition a city-wide coalition of over 25 hospitals, primary care providers, and community organizations, is working  with others to deliver better healthcare to vulnerable individuals in Camden N.J.

Inefficient and ineffective care of these patients has been identified as a driver of unnecessary healthcare spending in the U.S. AARP www.aarp.org, The Atlantic Philanthropies www.atlanticphilanthropies.org, and the Robert Wood Johnson Foundation (RWJF) www.rwjf.org are collectively going to provide $8.7 million to fund a National Center to Improve Care for Complex Patients.

Jeffrey Brenner MD, Executive Director for the Camden Coalition, reports, “The Coalition began to gain national attention more than a decade ago when they found that 20 percent of patients accounted for 80 percent of hospital costs in Camden N.J. due to disorganized care. “

Brenner and his colleagues found that by identifying these patients, improving the transition from the hospital to the home, and providing medical with social support could successfully reduce costly hospital visits.

The Camden Health Information Exchange (HIE) www.camdenhealth.org/programs/health-information-exchane funded in part by the Merck Foundation www.merck.com is really helping to link patient data across systems to improve care delivery. HIE participants include hospitals, primary care practices, laboratory and radiology groups, social service organizations, correctional facilities, and other licensed healthcare facilities and providers.

According to Brenner, “Every day the system generates a list of patients who have gone to a hospital, identifying their primary care doctor. Sometimes the primary care doctor has no idea which patients have gone to the emergency room. The system is succeeding since every time a patient goes to the emergency room or is admitted to the hospital, their doctor now has access to that information.”