Dates of Project: February 2006 through September 2013
Description: In Camden, New Jersey, hospital costs reach more than $100 million every year for its 77,344 residents. Some 30 percent of these costs come from just 1 percent of patients. Many of these patients either frequent the hospital EDs and inpatient wards, visit emergency rooms habitually for easily treatable conditions, or seek care for advanced conditions that could have been prevented if diagnosed and treated earlier.
To address this problem, the Camden Coalition of Healthcare Providers (CCHP) developed a care management initiative, Link2Care, which enrolls these high-utilizing patients while they are in the hospital and helps them after discharge to connect with primary care and receive the range of services necessary to reduce unnecessary hospital utilization.
Between September 30, 2012 and September 30, 2013, Link2Care identified 269 patients eligible for the intervention and assigned them to a care team. Of the eligible patients, 146 were enrolled in the initiative.
Between the launch of Link2Care in mid-2012 through early 2014, CCHP has made substantial progress in meeting its goal of getting patients into primary care within seven days of hospital discharge, which has decreased the average number of days to initial primary care visit from 22.21 at the start of the initiative to 8.00 in early 2014.
Patients enrolled at least six months in Link2Care (80) showed a 46 percent reduction in average hospital admissions in the six months after enrollment (1.7 visits) compared with the six months before enrollment (3.2 visits). However, no comparison group that could allow determination of a true statistical difference was studied.
In many regions across the country, robust “super-utilizer” programs providing intensive outpatient care management to high-need, high-cost patients are beginning to emerge.
Cleveland Medical Center Aims to Improve Care for Super Utilizers
MetroHealth will provide more care to 150 patients with diabetes, hypertension, and heart failure for 18 months. Then it will compare the before and after costs.
A Revolutionary Approach to Improving Health Care Delivery
Jeffrey Brenner, MD, created a model for improving care while reducing costs for complex patients who are "superutilizers" of the health care system. After using claims data to identify these patients, teams offer personalized care management.