Integrated Diabetes Care Program
Location: Camden, New Jersey
The Camden Coalition of Healthcare Providers (The Coalition) aimed to improve the quality, capacity, and accessibility of healthcare for vulnerable populations in Camden, New Jersey. The Coalition established the Camden Citywide Diabetes Collaborative to improve diabetes care at the patient, practice, and community levels, and the Integrated Diabetes Care Program to provide coordinated diabetes care for patients with the highest healthcare utilization. Using a team of nurses, Community Health Workers, practice coaches, and other specialists, the Coalition sought to strengthen diabetes care directly through care management for the most complex patients, in primary care offices, and in classes for diabetes self-management.
- Developing and implementing a patient-centered model of care proved successful in allowing providers to spend dedicated time with patients to understand their unique needs and address challenges through a coordinated team by meeting patients where they are.
- Providers are changing the culture of their practice, restructuring their workflows, and changing how they understand and interact with patients, and transforming the way they provide care.
- Building and maintaining a supportive, innovative culture is cultivated through practices of open dialogue, celebrating successes (no matter how small), continuous evaluation and correction, and exposure to ideas outside the organization.