Katharine Royer, MSc, BSc and Carolyn Junior, BSc

1. Superutilizer Success: Preventing rehospitalizations of a patient with uncontrolled diabetes 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 Why: Systems-Based Learning • The Who: Julia • 57 yo who lives in North Camden with two sons • Worked as instructional aide for 18 yrs Home Visit Clinical Coordination Social Coordination Specialist Visit Caregiver/Family Coordination Phone Medical Appointment Scheduling Community Medical Transport Planning Hospital 5% 6% 3% 10% 7% 1% 4% 3% • 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 78% 83% Care Coordination (23.37 hrs) Patient Encounters (58.75 hrs) Intervention • 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 IP IP Acknowledgements CMMI “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, NJ Rebuilding Together MANNA Generations Plus 5 IP 4 Length of Stay (Days) 3 IP 2 ER ER 1 Feb. 26 Mar. 3 Dec. 13 Dec. 16 Dec. 27 Sept. 28 2013 2012