Transcript 40 Weist Camden Coalition Presentation Slides

Healthcare
Hotspotting:
A Data strategy for
delivering better care to
individuals with complex
health and social needs
Criminal Justice-Behavioral Health: Partnerships Creating Integrated Healthcare
San Antonio, TX January 29-31, 2017
Overview of the Camden Coalition
We are a citywide coalition of hospitals, primary care providers, and
community representatives that collaborate to deliver better
healthcare to our most vulnerable citizens. We innovate and test
health care delivery models to improve patient outcomes and reduce
the cost of their care using data driven, human-centered practices.
Camden Coalition of Healthcare Providers
Healthcare hotspotting is the
strategic use of data to target
evidence-based services to
complex patients with high
utilization.
These patients are experiencing
a mismatch between their
needs and the services
available.
Outlier patients in the long tail of data
Healthcare hotspotting is the strategic use of data to
target evidence-based services to complex patients with
high utilization.
These patients are experiencing a mismatch between
their needs and the services available.
Camden Coalition Data Holdings
• Camden HIE: regional health information exchange that
brings together real-time clinical data to support
operations, including identifying patients for intervention
• TrackVia: cloud-based, HIPAA-compliant database that
allows the Coalition to track intervention workflows and
improve processes
• Camden ARISE: a longitudinal, archival integrated data
system of health care, social services, and social
determinants data for intervention planning, research,
and evaluation
38 Days
Week 10
2012
2013
2014
Hours
Week 1
Days To First Primary Care Visit
Days Since Last Engagement
Data for
Continuous
intervention
monitoring and
quality
improvement
168 Days
0
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Weekly staff hours with patients
12,541
people
overlap
18,755
people
with an
arrest
93,344
people
visiting the
hospital
226
people with dual sector
high utilization (DSHU)
5 years, ever having a Camden address
16+ emergency department visits
7+ police encounters
Prevalence of socio-behavioral complications
85%
90%
75%
80%
70%
70%
60%
50%
40%
30%
42%
29%
22%
22%
20%
7%
10%
0%
Substance abuse
Mental health
Violence/assault
hospitalization
Homeless
Segmentation for intervention planning:
Typical profile in each of four DSHU clusters
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Male, 18-29
Frequent arrests for drug
possession; no violent crime
arrests
Dx serious behavioral health
conditions
Medically complex, including
HIV
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Male, 18-29
Diverse arrest profile,
including drug trafficking,
property, violent crime
arrests
Compared to other
segments, lower medical and
behavioral health complexity
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Male, 40+
Extreme ED utilization, low
admissions
Public nuisance arrests,
rare drug possession
Housing instability and
homelessness common
Woman, 40+
Simple assault; infrequent
drug arrests
High hospital admissions,
including for assaultrelated injuries
Severe mental health
challenges; suicidal
ideation
Thank you for your time!
Dawn Wiest
Associate Director
Action Research & Evaluation
Camden Coalition of Healthcare Providers
800 Cooper Street, 8th floor
Camden, NJ 08102
(856) 365-9520
[email protected]