SYSTEMS-BASED LEARNINGBACKGROUND•915 individuals were homeless in Camden County in 2012•John was transitionally housed (considered homeless), living in a one bedroom apartment with two other adults prior to our intervention

PATIENT INFORMATION

Income: $210 in General Assistance$200 in Food Stamps

Insurance: Medicaid Package G (Out-Patient/ Under- Insured)

John is a 44 year old, father of three girls. He has worked as a professional wrestler, a mail carrier, and a truck driver. A trucking

accident in 2007 left him unemployed & eventually homeless.

Driving Diagnoses:•Seizure Disorder•Hypertension•Anxiety & Depression•Insulin Dependent DM

Psychosocial Stressors:•Homelessness (2009)•Lack of Family Support•Poor Medication Adherence•Intermittent Drug Use

May 2012 June 2012 July 2012 Aug. 2012 Sept 2012 Oct. 2012 Nov 2012 Dec. 2012 Jan. 2013 Feb. 2013 Mar. 2013

Intervention BeginsTimeline of Patient’s Hospital Utilization

System Failures Proposed Solutions

Incomplete Discharge >>>> Planning

↑ Insurance coverage↑ # of Medical Respite Centers↑ Housing options for Super-Utilizers

Provider Reliance on Patient >>>> Initiative & Reportingfdaf

> Prepackaged Medications> Use Electronic Medical Records

ACKNOWLEDGEMENTSCollaborative Support Programs NJThe Community Health Law Project

Center for Medicare and Medicaid Innovations

CARE TEAMJason Turi (RN, MPH), Angel Mitchell (LPN)

Raquel Medina (LPN), Sharine Eliza (Health Worker),Bill Nice (Intervention Specialist), Kelly Craig (CMMI Director),

Carolyn Junior & Katharine Royer (Health Coaches)

PATIENT UTILIZATIONEstimated Total Hospital Receipts

> Pre-Intervention: **$41,118 – Seizures and/or DKA> Post-Intervention: **$35,200 – Suicide Attempt

** This estimate cost data was compiled using The Camden Health Information Exchange (HIE)

InpatientED Visits

High Utilization in the Context HomelessnessCarolyn Junior, BSc Biology and Katharine Royer, BSc Biology, MSc Medical Genetics

Health Coaches with the Camden Coalition of Healthcare Providers; Camden, NJ

MEASURABLE OUTCOMES•Decrease in Patient Risk Score:

> Initial (Day 0) : 12 out of 24> 30 days: 9 1/12/13> 60 days: 11 2/12/13

The Intervention

• Medicine Reconciliation

• Provider Follow-up:

> Primary Care Ortho, Podiatry, PT/OT, Dentistry, Nephrology, Neurology,

• Provider Follow-up: > Psychiatry

• Coalition Accompani-ment

• Day programMedically ill,

Chemically Addicted (MICA)

• Accompany to Board of Social Services

• Emergency Housing

> Motel> Shelter

• Permanent Housing> CSPNJ support