Early efforts to target and enroll high-risk diabetic patients into urban community-based programs

Health Promot Pract. 2014 Nov;15(2 Suppl):62S-70S. doi: 10.1177/1524839914535776.


Health care disparities in minority populations can be attributed to a number of factors, including lack of access to coordinated primary care and chronic disease management programming. Interventions using a data-centric, coordinated, multidisciplinary, team-based approach to address patients with complex chronic comorbidities have demonstrated improvements in patient outcomes. The use of hospital admission and billing data coupled with care management teams to care for high-risk patients with chronic conditions may be an effective model for improving quality of care while reducing health care costs. This article describes how Camden city, the poorest city in the nation, has made headway toward developing an integrated approach to improving care while reducing costs for the city's most vulnerable.

Keywords: care coordination; complex care; data sharing; diabetes; health information exchange; hot-spotting.

MeSH terms

  • Community Networks*
  • Diabetes Mellitus / therapy*
  • Female
  • Home Care Services
  • Humans
  • Information Dissemination
  • Interdisciplinary Communication
  • Male
  • Middle Aged
  • New Jersey
  • Organizational Case Studies
  • Patient Care Management
  • Patient Selection*
  • Poverty Areas
  • Urban Health Services / organization & administration*