7-Day pledge shows results citywide in reconnection to primary care

Care management & redesign Quality improvement

Over the past 10 months, patients, providers, the Camden community and the Coalition have collaborated on a citywide initiative — to reconnect frequently hospitalized individuals in Camden with primary care within seven days of a hospital discharge.

The multi-faceted effort, led by the Camden Coalition, has been yielding promising results.

Evidence has shown that timely reconnection to primary care following a hospitalization reduces the risk of readmission and other complications.

The “7-Day Pledge” was launched in Camden’s primary care practices and through public meetings with the community. Physicians, medical staff, and members of the community were asked to take “the Pledge” and promotional items were emblazoned with the logo. The Coalition’s Community Advisory Council promoted the efforts at events around Camden, and Americorps volunteers visited all of the city’s primary care practices, bringing breakfast and meeting with practice staff to explain the pledge and garner support.

“We structured the 7-Day pledge like a political campaign,” said Dr. Jeffrey Brenner, the Coalition’s executive director.

Busy doctors were provided with more resources in order to support their work with the Pledge. Practices were paid $150 by the Coalition for each 30-minute post-hospital follow-up for recently discharged patients. Coalition staff visited the practices monthly to deliver the payments and review practice data with office staff, reinforcing the connection between the appointments and the additional payments. The Coalition also hosted provider dinners for physicians and their staff to celebrate their additional work on the Pledge.

The added resources made it possible for primary care physicians to set aside time each week to do thorough visits with some of the sickest patients with the most complex needs.

Patient barriers were also addressed with the Pledge, with the Coalition providing taxi vouchers to patients with transportation issues, and gift cards for attending appointments.

Results, tracked through the Coalition’s Health Information Exchange, are trending positively. In November of 2014, citywide only 26 percent of discharged patients in Camden were reconnecting with primary care within 7 days. In August of 2015, after 10 months of the 7-Day Pledge, the Coalition’s data is showing that 42% of patients were reconnecting within 7 days, and 52 percent within 14 days.

The preliminary results are encouraging. The Pledge will continue into 2016, with additional campaigns to come, supporting health care delivery reform in Camden with the goal of increasing the capacity, quality and access to health care in the city.