For patients and doctors, it pays to make appointments shortly after patients are hospitalized due to chronic conditions, as it reduces the chances for future readmissions — although it hasn’t paid off in terms of dollars and cents.
Until this year in Camden, that is, when an effort that rewards both doctors and their patients for making quick follow-up appointments is swiftly yielding good results.
The Camden Coalition of Healthcare Providers is paying doctors directly when they see patients within a week of a hospitalization. The coalition does this with funding through its Medicaid Accountable Care Organization – a new kind of healthcare-delivery arrangement that launched statewide this year and is aimed at broadly improving the health of residents in low-income areas.
The coalition’s effort, led by Dr. Jeffrey Brenner, is gaining the attention of healthcare leaders around the state, since the organization has a track record of initiatives that are copied in other communities and states.
Not only has it made quick progress on getting patients connected with primary-care providers, but it’s also making advances in connecting chronically ill patients with permanent housing and with behavioral health services to treat the mental illnesses and addictions that frequently accompany chronic diseases like diabetes and congestive heart failure. And it’s connecting its data system – known nationally for its use in “hotspotting,” or targeting healthcare where it’s most needed – to local law-enforcement agencies and school systems with the aim of further improving residents’ health.
The coalition, which is supported by local hospitals, is asking all Camden residents and primary care providers to sign a “seven day pledge.”
Brenner said there is strong evidence to back up the benefits of timely appointments in helping patients to manage their own health. And as the healthcare system increasingly uses dozens of measurements to pay providers based on their performance, the pledge provides a clear focus for doctors.
“We wanted to shape this like a political campaign,” Brenner said.
The coalition emblazoned a “7-Day Pledge” logo on pens and notepads, and sent AmeriCorps volunteers around the city, bringing breakfasts to every medical practice and meeting with staff.
Every practice had to produce a quality improvement plan “and everyone in the office had to sign off on it,” Brenner noted.
Brenner said fulfilling the pledge has been challenging for doctors who have tightly booked their schedules around “meaningless 15-minute increments.”
The coalition pays practices $150 for each 30-minute post-hospital follow-up visit within seven days. The coalition also sends a staff member to each practice, to physically deliver the checks and review where the data has improved, reinforcing a clear connection between the change the doctors and practice staff members have made and the additional money they receive.
“Getting our attention should be a paid activity,” Brenner said, criticizing a healthcare system that’s rewarded doctors more for ordering tests than for taking time to understand patients’ needs.
The coalition also provides taxi vouchers and gift cards to patients.
As a result of the pledge, doctors have made changes to their schedules, with some setting aside a specific time block each week to see patients who were recently hospitalized.
The results have been stark across all medical practices in the city, which range from large federally qualified health centers to small doctors’ offices. In January, early in the effort, four practices saw no patients within seven days of a hospitalization, while none of the rest saw more than 75 percent of patients that quickly.
In August, all 12 practices saw at least 17 percent of patients within seven days, with the highest seeing every recently hospitalized patient within a week.
Brenner, a 2013 MacArthur Fellow (the so-called “genius grant”), said patients benefit when doctors rearrange their schedule to focus on treating patients who need the most help, delegating other tasks to nurses and other staff members.
“We’re like elite chefs” at small restaurants who try to do everything, from taking customers’ orders to delivering the meals, Brenner said of primary-care doctors.
“When all 10 tables are full, the whole place falls apart – the food’s cold, you’re waiting for your food, the order’s getting mixed up, and it all starts to crumble,” Brenner said, adding: “We have to get our concierge chefs to protocol-ize, standardize, and delegate – and they’re artists, my colleagues are artists, so it’s a big shift.”
The “seven-day pledge” is occurring in the context of other coalition projects that aim to improve the delivery of healthcare to specific populations with serious health issues.
That includes an effort to shift from a model for housing for homeless people that’s based around shelters toward one focused on finding stable, safe homes. The coalition is looking to connect residents who find homes through a state-backed ”Housing First” pilot program with behavioral healthcare. Brenner said almost all homeless people have mental-health diagnoses, and 68 percent have both mental-health and substance-abuse issues.
The coalition also worked out an agreement with Camden County Police Chief J. Scott Thomson to combine arrest data with the coalition’s data. Not only are there many “cross-sector high utilizers,” but the coalition also has found that health issues, like substance-use disorder, and other problems like criminal behavior can reinforce one another.
“These are people who are not getting their needs but, and our systems are not arrayed to take care of them,” Brenner said.
A similar effort is occurring in conjunction with city schools, as the coalition has found links between high absenteeism and health issues.