The Camden Coalition serves as the Accountable Care Organization (ACO) for the city of Camden. That means we work closely with the city’s primary care practices, making sure the care being delivered is coordinated and high-quality. We also want to make sure that the patients enrolled in our care management intervention are connected with providers that understand their complex health and social needs after they graduate from our program.

One way we improve quality is reviewing monthly scorecards with our local practices. At monthly scorecard meetings, we meet with the administrative staff of each practice to go over the practice’s reconnection rate, scheduling rate, and no show rate for the month. Now we’ve added a powerful new tool to these meetings: patient stories.

Jeneen Skinner, Clinical Manager of Care Management Initiatives at the Camden Coalition, is one of the care team members bringing patient stories to ACO scorecard meetings. She says that patient stories allow us to bring in nuanced information that is missing from patients’ charts.

“In the charts it just says no-show, no-show, but why are they a no-show? There’s always a story,” she says. “Whether it’s homelessness, lack of access to a phone, lack of support, we find out those things because of the relationships we build with patients. Bringing these stories will help the practices see patients in a different light.”

One patient’s recent trauma highlights the importance of patient stories to good care. The day before Jeneen presented at one of our ACO primary care practices, a patient called the care team in crisis. Our care team had been working this patient for months, but what she revealed over the phone that day was news to them: she had been experiencing domestic violence and was now having thoughts of suicide.

“This is a patient who was involved with not only the practice, but our care management team, our ACO team, our data team, the hospital,” said Jeneen. “She was judged as a ‘super-utilizer’, but no one really knew what was going on at home. Because we had built a relationship with her over months, she felt safe enough to share this information.”

Jeneen said that it’s possible that the patient was using the emergency room as a safe haven from the violence she was experiencing at home, driving her patterns of high emergency room and hospital utilization. And her phone call not only demonstrates the trust the care team has built with her, but it represents a turning point in her care.

When Jeneen shared her patient’s story the next day at her primary care practice’s scorecard meeting, the practice was able to add information about the violence the patient was facing at home to her chart, and build a different care plan for her that prioritizes her safety.

“We always focus on patients’ strengths and what they do well,” says Jeneen. “Giving [primary care practices] that inside information and collaborating with them will help them provide even better care for the patients.”
Bringing patient stories to the ACO practices’ scorecard meetings is part of a larger strategy designed to bridge the gap between our intensive intervention and patients’ long-term care. “We’ve learned that our care management intervention works,” said Ramona Olivares, Program Manager for Stakeholder Engagement at the Camden Coalition. “But as we’re doing a warm handoff to the practice, we want the practice to have knowledge of the patient.”

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