Katharine Royer, MSc, BSc and Carolyn Junior, BSc

The Where: Camden, NJ•Population: ~77,000•42% live below poverty line•20% of patients account for 90% of healthcare costs

The Who: Julia•57 yo who lives in North Camden with two sons•Worked as instructional aide for 18 yrs

Medical History/Diagnoses

Reason for recent ER visits/admissions

Uncontrolled type 2 diabetesBilateral amputeeCoronary artery diseaseGastroparesisAnxiety/depression

Nausea/vomiting Abdominal painUncontrolled diabetesLack of social supportAnxiety/depression

The What: Our Intervention•Enrollment in day program

• Socialization & medical support•Referred to MANNA meal delivery service

• Access to balanced diet•Switched PCP

• Supportive relationship/patient empowerment•Increased HHA hours

• Diabetes management•Home Depot Wheelchair ramp donation

• Safety for getting in/out of house

The Why: Systems-Based Learning

Failures Successes

Provider relationshipsEducation

Medical Day ProgramsMANNA referral processFamily motivationNon-profit & corporate relationships

AcknowledgementsCMMI “Team Awesome”: Jason Turi (RN), Angel Mitchell (LPN), Raquel Medina (LPN), Sharine Eliza (Community Health Worker), Bill Nice (Intervention Specialist), Kelly Craig (Director of Care Management Initiatives)

Bill & Elizabeth at Home Depot, Delran, NJRebuilding TogetherMANNAGenerations Plus

Care Coordination (23.37 hrs)

Clinical CoordinationSocial CoordinationCaregiver/Family CoordinationMedical Appointment SchedulingMedical Transport Planning

78%

4%

7%6% 5%

Patient Encounters (58.75 hrs)

83%

Home VisitSpecialist VisitPhone

HospitalCommunity

3%

3%

1%

10%

Superutilizer Success: Preventing rehospitalizations of a patient with

uncontrolled diabetes

The How: Utilization/Cost Data•6 Months before intervention

• 3 IP Stays~$17,600 cost in receipts•2 Months after intervention

• 1 IP Stay~$8000 in receipts; 2 ED Visits~$906 in receipts

Len

gth

of

Sta

y (D

ays)

1

2

3

4

5IP

IP

IP

IP

ER ER

Sept. 28 Dec. 13 Dec. 16 Dec. 27 Feb. 26 Mar. 32012 2013

Intervention