The University of Massachusetts Amherst
University of Massachusetts Amherst

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Care coordination for ‘Complex’, High-Utilizing Patients: The Camden Coalition Experience


Monday, November 30, 2015 - 4:00pm


Hari Balasubramanian, Associate Professor, UMass Amherst


Kellogg Room, Elab II



In a 2011 New Yorker essay, the surgeon-writer Atul Gawande highlighted the work of a novel care delivery model in Camden, New Jersey. Conceived by Jeffrey Brenner, a family physician, the care model focuses on helping the sickest patients in Camden. These patients have multiple chronic conditions and often struggle with behavioral health, addiction and homelessness. In most cases, the patients have visited the emergency room and been hospitalized multiple times. In the process, they have been prescribed numerous and often confusing set of medications. The top 1% of such high expenditure patients account for 25-30% of Camden’s health costs. Yet, despite such high costs and utilization, the health outcomes of the patients do not show improvement. Rather a hospitalization is simply followed by another hospitalization and yet more medications. This is primarily due to a lack of sustained coordination that focuses on prevention. To address this problem, the Camden Coalition of Healthcare Providers (CCHP) reaches out to such patients with a team of nurses, social workers, community health workers and health coaches. The goal is to coordinate the patient’s clinical and social needs and educate the patient for a 90-120 day period until the patient is able to independently navigate the healthcare landscape.

The cost, health and psychological outcomes of this care delivery model are currently being rigorously tested in an ongoing randomized controlled trial. However, the burden of coordination, that is the time effort invested by different members of the care team and the implications on capacity planning, such as how many patients can be enrolled in the program at any time, have not been studied. It is important to study this because intensive-outreach programs are now slowly being adopted nationwide in an attempt to bend the cost curve, yet data-driven evidence on the effort involved is scant. In this talk, I will discuss descriptive results from a unique CCHP dataset for 465 patients collected in a 128-week period. I will also briefly touch upon an ongoing collaboration along similar lines with a community health center in Holyoke, MA. 

Bio for Hari Balasubramanian

Dr. Hari Balasubramanian is Associate Professor of Industrial Engineering at the University of Massachusetts, Amherst. After receiving his doctoral degree at the Arizona State University in 2006, Amherst, Dr. Balasubramanian spent two years as a Research Associate at Mayo Clinic in Rochester, Minnesota. He joined at the University of Massachusetts in September 2008. His research interests are in operations research methods applied to healthcare.