Improving transitions in care: Camden Coalition of Healthcare Providers' Improving Care Transitions for High Needs, High Cost Patients in Camden

The Foundation's program, New Jersey Health Initiatives, was designed to support projects in New Jersey that develop new approaches to resolving the state's health care needs, focusing on the Foundation's goal areas.The Camden Coalition of Healthcare Providers (CCHP) is a nine-year old organization working to improve the quality, capacity, and accessibility of the healthcare system for vulnerable residents living in the City of Camden. This grant will provides funding to embed trained nurse coordinators and health coaches in two primary care practices in the City of Camden to improve care transitions for the most complex, costly, and high utilizing patients with a goal of reducing unnecessary hospital use. The project will target 400 high cost/high utilizing patients through embedded CCHP nursing staff and health coaches placed at CAMcare, and Project HOPE, both Federally Qualified Health Centers. Cooper, Our Lady of Lourdes, and Virtua hospitals will provide claims data, clinical data, and actively participate in the Coalition's monthly citywide Care Management meeting. The hospitalist team at Cooper will continue to work closely with CCHP. The staff at Steininger Behavioral Health and South Jersey Behavioral Health, regional non-profit organizations with behavioral health programs, and the Volunteers of America, a non-profit that operates homeless shelters in Camden, are also active participants in a county-wide high utilizer leadership task force organized by the Coalition to develop new referral networks for the most extreme high utilizers in Camden.

Grant Details

Amount Awarded $300,000.00

Awarded on: 6/29/2011

Time frame: 7/1/2011 - 6/30/2013

Grant Number: 69124