1. Camden Coalition of Healthcare Providers Primary Care Redesign Webinar Nadia Ali, Director, Clinical Redesign Victoria DeFiglio, Associate Clinical Director

2. Overview Rationale Care Coordination Framework Program Success to Date Staffing Model Patient Impact Practice Transformation Looking forward Q & A 3. Care Coordination Framework www.camdenhealth.org PatientsLevelof Dependence Time PUSH Bedside Higher Warm Hand-off CARRY CATCH 4. Rationale 5. Program Success to Date A1c reduction seen in 67% of patients to date Seen decrease in hospital utilization and 30-day readmissions Improved linkages, greater collaboration between diabetes educators and primary care providers Greater Patient Satisfaction Standardization of practice protocols 6. Our Embedded Team SWRN LPN HC HC CHW 7. Patient 8. Patient Pre-Intervention 13 30-day readmissions Post-Intervention 2 30-day readmissions. 9. Provider 10. Vision for Primary Care Care Coordination Nurse Care Transitions Accompanied PCP visit Care coordination rounds Accompanied specialty visits HIE training Social work assistance Quality Improvement Patient registries Team meetings Protocols Provider/staff Education EMR Meaningful Use assistance Data collection/analysis Patient Engagement Chronic Disease self- management education Group medical visits Mental health assessment & counseling Peer support groups Wellness programs