How to Implement a Care Management Model

The research article includes two key findings:

• Among patients who were most likely to engage in care management, the relative 30-day readmission risk for intervention participants was 48% lower than the control group.
• The relative 90-day readmission risk was 52% lower.

The Camden Coalition’s care management model features a multidisciplinary team, says Kathleen Noonan, JD, president and CEO of the nonprofit. “Our care management program has always been a nurse and community health worker team, with a social worker who is connected to each team. We basically enroll a patient in the hospital—we use data from our health information exchange to identify complex patients with complex medical issues and complex social needs. Our local hospital, Cooper University Health Care, let’s our enrollment managers work on the inpatient floors, and we try to enroll people in our program.”

The care management team conducts community-based work with patients, she says. “They are the ones who are doing the care planning, working with the patients to see what they think their needs are, and working with patients around the health issues that brought them into the hospital. If you are enrolled in our care management program, you have been in the hospital for at least two times in the past six months. So, these patients have a lot of interaction with the healthcare system.”

The Camden Coalition’s care management model benefits healthcare providers and their complex patients, says Louis Bezich, MPP, senior vice president and chief administrative officer at Cooper University Health Care, which is a member of the coalition.

“It plays a supportive role that leverages and coordinates the partners to maximize the value of their work such as my hospital or a federally qualified health center. The Camden Coalition connects the dots. Early on, the Camden Coalition focused on care coordination and meeting patients at the bedside to make sure they had follow-up visits scheduled. It has focused on the social determinants of health—the identification and documentation of social determinants of health and how that is a critical gap that needs to be filled in order for patients to maximize the value of the healthcare they receive,” he says.

In addition to staffing, resources applied to the Camden Coalition’s care management model include housing and legal assistance, Noonan says. “Because of the barriers that we see for our patients, we created a housing program called Housing First, in which we enroll some of our patients. We also created a Medical Legal Partnership (MLP) program, where we have an attorney who works with people who have complex social needs because those needs sometimes involve the courts. So, we created new resources where we saw gaps.”

The Housing First program costs about $15,000 per person annually, and the MLP costs under $5,000 per client, she says. The care management model has a high return on investment because it can avoid multiple hospital readmissions for patients, with each hospital readmission costing at least $10,000, Noonan and Bezich say. “The return on investment is also lower recidivism in the use of the emergency department and less healthcare spending overall because patients get well,” Bezich says.

Replicating the care management model

Healthcare providers across the country can implement the Camden Coalition’s care management model at their organizations, Noonan and Bezich say.

“This care management model can absolutely be replicated at other healthcare providers. We train people on our approach to patient care. We train people on how to work with community partners. We also have protocols for how we conduct care management. Our model and the tools we use are written down,” Noonan says.