Credit: (AP Photo/Damian Dovarganes, File)A fresh look at a nearly decade-old effort to reduce hospitalizations for Camden residents with significant medical and social needs shows that while the intervention didn’t drive down admissions, it likely improved patients’ health and welfare.
Research published in the journal Health Affairs in late December confirmed previous findings about a program by the nonprofit Camden Coalition, showing that the assistance of a care manager did not reduce readmissions for previously hospitalized patients. Many of those patients were homeless, diagnosed with substance use disorders or serious mental illness, or faced similar challenges. The Coalition was launched in 2002 to improve care for Camden area residents and now runs an award-winning national program designed to better serve patients with complex needs.
“It’s a qualified success,” said Joel Cantor, director of the Rutgers Center for State Health Policy, which provided data for the review. “Life is more than just not getting hospitalized.”
For people with complex, chronic conditions, hospitalizations reflect poor disease management, Cantor said. “The fact that [re-admissions] didn’t improve, that is a problem,” he said. ‘But getting good primary care is important for lots of reasons, not just keeping us out of the hospital.”
More work to do
Kathleen Noonan, CEO of the Camden Coalition, said the latest findings were gratifying for the staff, indicating that their efforts can make a difference, but also showed they have more work to do. “We are certainly thrilled to be able to say we have an evidenced-based care-management model that has been shown to connect individuals with very complex health and social needs to resources they need, like primary care, specialty care and durable medical equipment,” she said. The program also helped connect patients with federal nutrition assistance or SNAP, once known as food stamps, she added.
“The study was dealing with a very, very complex population,” Noonan added, “so to understand there is a way to engage people and a way to actually get them connected to care is really important.”
The research is also informing how the Camden Coalition shapes programs going forward, Noonan said. The nonprofit plans a more in-depth study on what exactly drives people to seek hospital or emergency room care, she said, and is working with a national organization to better understand the individual impact its programs have on patients. The Coalition is also working with hospital systems, behavioral health providers and community groups to better knit together a regional safety net and has hired a full-time housing coordinator to assist patients, she said. It also continues to operate a small care-management program, she noted.
‘My major takeaway is you really have to think of the health care system being broken on multiple levels.’ — Joel Cantor, Rutgers Center for State Health Policy
“It’s hard for us to think about stabilizing people until they’re in housing, which could take six to nine months [from] when we first start working with them,” given the challenges involved, Noonan said. “The work shows us that the challenges that this population face can’t be solved by a single health care system, or social care provider.”
For the same reason, hospital readmissions, especially within 30 days, are considered a red flag that could indicate a medical error, hospital-acquired infection or general breakdown in care. But patients are also readmitted when they fail, or are unable, to properly follow up with medications, wound care or other requirements. Patients who are Black and Hispanic — the majority in Camden — have higher readmission rates than white people, according to federal data.
The Camden Coalition’s work on reducing readmissions dates to at least 2007 and some models showed promise, according to a study published in 2019. But a randomized, controlled trial launched in 2014 with 800 participants showed that patients who had been visited by a care manager returned to the hospital at the same rate as those who had merely received a printout with discharge instructions, according to an analysis by the Massachusetts Institute of Technology’s Abdul Latif Jameel Poverty Lab, or J-PAL.
Tracking down patients
The new Health Affairs review, which examined Medicaid data for 70% of the original study participants, also considers why the care-manager interventions didn’t have a greater impact on the rate of hospitalizations. Among the challenges of working with the high-needs patient population was finding them, it appeared, as researchers noted that key program goals — a care manager visit within five days of discharge from hospital and a doctor’s visit within a week — were met less than 30% of the time.
Noonan said connecting with potential patients was also difficult at times during the COVID-19 pandemic when the Coalition redirected nurses who traditionally teach complex-care strategy elsewhere in the nation to help run vaccination clinics in Camden. Despite having staff and stocks of vaccines, few people came for immunizations at first, she said.
“COVID taught the Camden Coalition that sometimes you have to ask 20 times,” Noonan said. “We had to knock on doors and knock on doors again. We had to go to the Cherry Hill Mall. We had to go to high school basketball games.”
“We did just everything and, if we gave one shot that day, it was a victory,” she said.
For Cantor, who has studied the state’s Medicaid system for years, the Health Affairs report also underscores the barriers these patients face, many of which lie outside the purview of the health care system and aren’t covered by the publicly funded insurance program. “My major takeaway is you really have to think of the health care system being broken on multiple levels,” he said. “What this intervention did was substantially overcome sort of the first step in the process that was broken, which is getting people into care.”
