Perry is talking with us today about a program that she works on as a part of the Camden Coalition of Healthcare Providers. What we’re hoping to do is get a general sense of what you and Jason are going to let folks know about at the Conference.
Why don’t you give me an overview of the program itself in terms of who the team members are, who the patients are, what the model is, where the care takes place – just kind of the basics of who, what and where.
Perry: Our program, is called the “Care Management Initiative”. What it is is a short-term – about 30-60 day intervention – that works with vulnerable patients in the Camden City area. Camden is a city in New Jersey, which definitely experiences – as does many cities across North America or a large population of people living in poverty. Many of these individuals also have complex medical problems, which sends them in and out of the hospital. What we do is target patients who utilize the hospital in the emergency room frequently.
Our patients generally --- the eligibility to be on our panel is that they have to have at least two in-patient stays or emergency department visits within the past six months and one or two of several chronic conditions that we work with like diabetes, asthma, things of that nature. So, our care team is interdisciplinary. We have a social work, RN, LTMs and intervention specialists and health coaches – that’s my role – all on board to help coordinate the care of these patients.
So, from the time that they are enrolled to the time that they graduate from the program, what we try to do is really help coordinate their care better across the board. Many of these patients are going in and out of the hospital because they don’t have the proper coordination between their different providers or just haven’t been to a primary care doctor in quite a long time. So, we help to reintegrate them into the healthcare system, get them connected to a primary care physician if they aren’t and also help connect them to other social services that will make it easier for them to take care of themselves – things like food delivery or food assistance if they need that, as well as connecting them to transportation, which is a big issue for many of our patients.
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To hear more from Perry, please join us at the 22nd Annual Medicaid Managed Care Congress, May 19-21 in Baltimore, MD.
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