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In Camden, Intensive Care for Diabetics

A new approach to chronic diseases like diabetes closely coordinates patient care and follow-up to improve treatment and reduce costly ER visits and hospital stays.

A program to deliver intensive diabetes management to help bring the disease under control is being launched by the Camden Coalition of Healthcare Providers (CCHP), according to executive director Dr. Jeffrey Brenner. He indicates that nearly $4 million in grants is enabling the coalition to deploy nurses, health coaches, endocrinologists, and diabetes educators into five of the city's medical practices.

The primary care practices are being chosen by a competitive process, said Brenner. The first is slated to open next month. The executive director, a nationally known urban healthcare pioneer, cofounded the CCHP in 2002.

The coalition is what's known as an Accountable Care Organization (ACO), a group dedicated to improving the treatment of chronic conditions, like diabetes, as well as reducing emergency room visits and hospitalizations and coordinating patient care. The idea, which is a key feature of the Affordable Care Act, is to provide higher-quality care at lower cost.

Coalition members include hospitals, doctors, behavioral health providers, and nonprofits focused on improving healthcare in the city.

What often happens in Camden, said Brenner, is that a diabetic may be "admitted to the hospital for high blood sugar and discharged after a week" with a discharge form that most laymen can't read. "Then no one calls the patient and no one visits," he added.

In the new model, "the nurse will go to the hospital, do the discharge plan, follow the patient home, sort out the meds, and give the patient instructions," Brenner explained. And that same nurse "will be there when the patient comes in for the first office visit and sit in on the weekly case conference," he continued.

"In order to lower costs and improve quality, you need to pay attention to sick people," Brenner said. "You need to know who is in the hospital, who is leaving the hospital, where they live, and who is responsible for them." The reality in primary care is that "everyone is super busy and overextended and running from patient to patient and no one pays attention to the really sick people," Brenner said.

According to Brenner, the new approach is "a very deep focus on the most costly and complex diabetics." The 10-minute doctor visit may work for routine cases but "it is a broken model when you're dealing with a complex 60-year-old diabetic with [high] blood sugar, heart failure, and high cholesterol."

Over the next year, the five practices will develop the new care model for about 600 diabetics. There are more than 6,000 diabetics in the city, and the goal is to extend best practices in diabetes management throughout Camden.

Brenner said the coalition is trying to improve primary care "though the lens of diabetes. When you fix something, it works better for everyone. This is about primary care capacity-building, and the outcome will be better primary care for everyone."

Coalition member Dr. Jon M. Regis, president of Reliance Medical Group, said his decision to open a primary care office in a Camden housing development illustrates how tough it is to change medical care in the city. Several months ago, Reliance opened an office in the 400-unit Northgate II, which he said "has a high use of the ER, one of the highest in the state." He said Reliance renovated a suite of offices in the building and has a doctor there two days a week, and staffs the office five days a week.

"Unfortunately we have not had the use we would expect," said Regis. The office sees about 10 patients a week. "We are really disappointed with the response, and we have done multiple marketing efforts and knocked on doors," he said, adding that many of the residents would rather get primary care in the ER and others simply choose not to go to the doctor until they are sick -- and then go the ER.

Regis said he doesn't know how much longer he will maintain the office. Reliance has 18 offices in three counties, including four in Camden, and can't afford to keep an underutilized office open indefinitely.

Getting hospitals, labs and doctors' offices to convert to electronic medical records has been a high priority of the coalition for years and is helping improve the treatment of diabetics, said Brenner, who explains that under the traditional "out of sight out of mind" system, a family doctor doesn't necessarily know when a diabetic in the practice enters the hospital. The ACO model is dependent on electronic medical records, so that they are immediately accessible to all doctors and hospitals treating a patient.

For the past year, Camden has linked medical providers into an electronic health information exchange. The city's three hospitals "are feeding data in real time into a web [portal] that is accessible to the providers. It has labs, radiology results and hospital discharge summaries," commented Brenner. Primary care doctors in the city use passwords to log into the system and get results for individual patients.

Lawrence Downs, chief executive officer of the Medical Society of New Jersey, said Camden is considered one of the most medically wired places in New Jersey: "Camden may be the most connected from a healthcare standpoint; they have gotten the various healthcare providers all connected and sharing information."

Bob Hockel is vice president for ambulatory services and development at Virtua Camden, a coalition member that operates an emergency department in the city, as well as a primary care practice with 22,000 patients. He said the practice is putting all patient records into digital form and expects to complete the process by early next year.

"Our goal, and the goal of healthcare reform, is really to manage health outside the hospital, because the hospital is where the cost is most expensive, and it is better for costs and outcomes to provide the care in the community," Hockel said.

The coalition’s diabetes initiative is being funded by grants from the Bristol Myers Squibb Foundation and the Robert Wood Johnson Foundation. BMS said its $3.45 million, five-year grant will support care coordination, patient management, and community mobilization. RWJF said its $300,000 grant will enable the coalition to embed trained nurse coordinators and health coaches in two practices to improve care transitions for the most complex, costly, and ER/hospital-dependent patients with the goal of reducing unnecessary hospital use.

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