A Coalition Creates a Citywide Care Management System

Increasing and improving access to primary and specialty care for Camden's most vulnerable residents

The Camden Coalition of Healthcare Providers is a collaborative of practitioners, health centers and hospitals in Camden, N.J., across the Delaware River from Philadelphia. The 2005 U.S. Census found Camden to be the poorest city in the country, with 44 percent of the population living below the poverty line.

Starting in 2003, the coalition built a citywide health database of claims data from the three local hospitals. These data showed that 50 percent of Camden residents visited a local emergency department or hospital in a single year, twice the rate for the United States overall. The majority of the visits were for preventable conditions that are treatable by a primary care provider.

To reduce unnecessary emergency department and hospital utilization for vulnerable populations in Camden, the coalition created a citywide care management system. A team—comprised of a family physician, nurse practitioner, medical assistant and social worker—works with high emergency room and hospital users, providing transitional primary care aimed at moving patients to an appropriate primary care setting. RWJF supported the development of this system through a second grant under the New Jersey Health Initiatives.

Over the three years of the project (July 2007 through July 2010), the care management team provided outreach to about 312 patients and assessed their medical and social needs. As of June 2010, the team was actively managing 108 patients.

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