A citywide pledge to reduce readmissions

Camden, N.J., focused on removing barriers to postdischarge primary care visits.


Medicaid covers 57% of residents in Camden, N.J., compared with 20% nationally. Patients covered under Medicaid may face more barriers to follow-up after hospitalization, and research by the Camden Coalition of Healthcare Providers showed that patients who saw primary care clinicians within seven days of discharge had lower readmission rates. That gave the Coalition a natural goal.

“We decided on one metric that all of us could get aligned around,” said Carter Wilson, MCom, associate director of clinical redesign initiatives at the Coalition, which is a Medicaid accountable care organization (ACO).

How it works

When the program launched in 2014, the Coalition asked physicians and staff at local primary care practices to take the 7-Day Pledge to provide timely follow-up. A listening campaign with participating practices found that patients' barriers to primary care included transportation and long wait times, said Natasha Dravid, MBA, director of clinical redesign initiatives. Plus, for many practices, there was a high no-show rate, she said.

To address these barriers, social workers and community health workers discussed the benefits of follow-up and scheduled visits with patients before discharge, either at the hospital bedside or by telephone. “The Camden Coalition was already running a high-touch care management intervention, so we had a team of social workers and community health workers who were going to the bedside for other workflows,” said Ms. Dravid, adding that the Coalition also uses its own health information exchange.

Patients who scheduled appointments were offered transportation by taxi to and from the primary care office (about 25% took the offer), as well as a $20 gift card after appointment completion. Meanwhile, practices were offered financial incentives on top of regular reimbursement and value-based payments: $100 for visits within 14 days and $150 for visits within seven days. “It was a signal to them that we understand that primary care is under-resourced,” said Ms. Dravid. The resources to run the program and provide the financial incentives came from the Coalition's ACO contracts with managed care organizations.


Of 1,531 patients targeted by the program from Jan. 1, 2014, to April 30, 2016, 450 (29.4%) had a primary care visit within seven days of discharge, 607 (39.6%) had a visit within 14 days; the other 924 (60.4%) had no visit within 14 days. Patients who attended a primary care appointment within seven days of discharge had significantly fewer 30- and 90-day readmissions compared with patients who had a later primary care visit or none, according to results published in January 2019 by JAMA Network Open. “We had been monitoring the program over time since implementation . . . and based on what we were seeing, we anticipated the results would go in that direction, but we weren't sure. The research literature [on similar interventions] shows mixed results,” said Dawn Wiest, PhD, director for research and evaluation at the Coalition.

In a simple analysis of the program's fixed costs ($230,000 per year) and variable costs (roughly $200 per visit), using an estimate of $10,300 in cost savings per avoided hospitalization, the team determined that the program would break even if 27 readmissions were avoided annually by connecting 208 patients to primary care within seven days of discharge. To do that, staff would need to engage 694 patients per year, or fewer than three patients per workday, which is a reasonable amount, said Ms. Dravid.


One challenge of the project was keeping motivation to schedule patients high among practices, so the Coalition did a March Madness game to help increase engagement, said Mr. Wilson. “We pinned the practices against each other in the reconnection rates, and the moment we announced it in mid-February to when it was done, reconnection rates shot up,” he said. Another obstacle was data integrity, since data were collected from many different practices.

There were also 52 patients who declined to schedule appointments and 219 who were lost to follow-up. “If we can get to you at bedside, there's a good chance we can get you into primary care,” said Mr. Wilson. “Where we lose people is if our data are a little lagged and we aren't able to meet you at bedside and we have to do a telephonic workflow, which is always really hard, particularly with the Medicaid population.”

Words of wisdom

The 7-Day Pledge is scalable and could be replicated, said Ms. Dravid. “At its core, this program is about building relationships. If you have a simple data feed and an idea of where to start . . . I think it is replicable in a lot of different ways by health systems, by health departments, by nonprofits,” she said. Mr. Wilson added that a health information exchange is not necessary to start. “If you have agreements with other partners that are willing share data, encrypted Excel sheets can get you somewhere.”