The Urban Health Institute of Cooper University Health Care is a business unit dedicated to redesigning and improving care delivery to underserved populations, specifically Camden based Medicaid and Medicare beneficiaries. The Institute was founded with seed funding in 2013 from The Nicholson Foundation and Cooper to redesign outpatient primary and specialty care for those with the most complicated social needs, and difficulty accessing medical care.

Cooper University Health Care delivers high quality clinical care, while simultaneously innovating through learning from around the world. Recognized by Chris Trimble in How Physicians Can Fix Health Care: One Innovation at a Time and the American Public Media’s Marketplace segment, “Diagnosis Data,” The Urban Health Institute brings hallmark programming from national and international leaders in innovative practice models and approach to care for vulnerable patient populations to Cooper- a health care organization with 130 years of commitment to caring for the city of Camden.

Based on the learnings of the Camden Coalition of Healthcare Providers, the Southcentral Foundation, Commonwealth Care Alliance, the Aravind Eye Hospital, and Spectrum Health’s Center for Integrated Medicine, it carries out this function through data-driven practice transformation and adaptation of international best practices for cost-effective community healthcare. The UHI’s medical practices are located in Camden, NJ, at the Cooper Advanced Care Center (CACC) and Cooper Family Medicine at the Kroc Center. Both are bustling outpatient multispecialty practices with 23 specialties including primary care, addiction medicine, medical specialties, orthopaedics, and surgery. Through these practices, UHI participates in the community-wide Medicaid Accountable Care Organization with the Camden Coalition of Healthcare Providers. While responsible for 5 percent of the Camden managed Medicaid capitation to Horizon and United, 25 percent of the ACO’s high utilizers call the CACC and Kroc Center their medical homes. In addition to supporting this panel, UHI works closely with Cooper’s Transitional Care department to coordinate with providers, families and high risk primary care patients following a hospital admission.

Easy-to-access appointments with nurses for weekly management of high blood pressure and diabetes are a stand-out feature of UHI’s primary care practice. Providing twice the face-time with a qualified clinical team member at half the cost, nurse-led protocols offer unprecedented access to chronic disease management in our practice. Other innovative care models include group medical visits for chronic diseases such as headaches, opioid use disorder, and diabetes as well as care coordination and health coaching for patients with complex medical and social needs. Recently, Cooper supported UHI’s addiction medicine specialty service in response to a top concern in Camden’s 2013 Community Health Needs Assessment. This program offers special care pathways for pregnant women and uses individual and group medical visits for patients at various stages of recovery.

Operational Improvements

Optimized Appointment Scheduling to Improve Physician Utilization

  • Problem – 45 percent of UHI’s patients no-show for their appointment, compared to private payer practices, which typically have a 5 percent no-show rate.
  • Solution – UHI developed a computerized predictive model which uses key data points to predict patient show-rate, including past history, appointment wait time, age, payor, and specialty.

Results:

  • Provider utilization +14 percent
  • Extremely under-utilized provider sessions reduced by 75 percent
  • Extremely over-utilized provider sessions – no change
  • Patient wait times for appointments reduced by 4-6 weeks

Supporting High Utilizers and Frequent Users of the Emergency Department

UHI provides care management for vulnerable populations following a hospitalization or emergency room visit.

  • Visit
  • Triage
  • Initial bedside care planning
  • Bedside engagement

Bio-Psycho-Social Support: Patient Engagement

  • Your doctor knows you’re in the hospital
  • Rapport-building
  • Motivational interviewing
  • Brief needs assessment
  • Facilitation
  • Accompaniment
  • Warm hand-off
  • Responsive to needs beyond PCP/hospital follow-up
  • Patient as expert