Early Efforts to Target and Enroll High-Risk Diabetic Patients Into Urban Community-Based Programs

Abstract

Health care disparities in minority populations can be attributed to a number of factors, including lack of access to coordinated primary care and chronic disease management programming. Interventions using a data-centric, coordinated, multidisciplinary, team-based approach to address patients with complex chronic comorbidities have demonstrated improvements in patient outcomes. The use of hospital admission and billing data coupled with care management teams to care for high-risk patients with chronic conditions may be an effective model for improving quality of care while reducing health care costs. This article describes how Camden city, the poorest city in the nation, has made headway toward developing an integrated approach to improving care while reducing costs for the city's most vulnerable.

Demographic and Clinical Predictors of High Healthcare Use in Patients with Inflammatory Bowel Disease

“…The combination of racial and socioeconomic disparities has been previously identified as a detriment to adequate healthcare and a risk factor for high healthcare utilization. (23, 24)…”

“…Regardless, other studies have shown that other minorities including Hispanics have limited access to care and are associated with higher utilization patients in a variety of diseases. (23) While this study defines conditions associated with high expenditures, it does not define the directionality of the relationship. Further studies are needed to determine the cause and effect.…”

Cross-Site Evaluation of the Alliance to Reduce Disparities in Diabetes

“…Health care system change included care coordination, use of diabetes registries or electronic medical records, nurse or community health worker participation in care management, enhanced community partnerships, and policy changes. Details of these programs and their specific strategies are described elsewhere (Collinsworth et al, 2014; Goode & Jack, 2014; Johnson et al, 2014; Kaufman et al, 2014; Langwell et al, 2014). …”

“…Instead, sites were encouraged to implement programs that addressed the needs of local communities. The programs are described in other articles in this special issue (Collinsworth, Vulimiri, Snead, & Walton, 2014; Johnson et al, 2014; Kaufman, Ali, DeFiglio, Craig, & Brenner, 2014; Langwell, Keene, Zullo, & Ogu, 2014). This article reports on the cross-site evaluation of the Alliance programs, including clinical and patient-reported outcomes…”

Medication Nonadherence, Health Care Utilization, and SafeMed Care Transitions Model Impact in Super-Utilizers

“…The SafeMed model differs from earlier care transitions models by focusing explicitly on high risk super-utilizers of inpatient and emergency services rather than all hospitalized patients targeted by hospital-focused care transitions models such as Project Boost, 61 the Bridge Program, 62 and Project RED. 63 And unlike other super-utilizer focused care transitions models such as the Camden Coalition, 64 the Coleman Care Transitions Program, 9,65 and the Naylor Transitional Care Model, 66 SafeMed focused on proven medication therapy management approaches 19,42 using program pharmacists and pharmacy technicians as key team members.…”