The Camden Coalition of Healthcare Providers' Care Management Program: Link2Care, is considered one of the most promising ways to reduce healthcare costs and improve patient health at the same time. The program targets super-utilizers of the health care system - specifically adults with two or more hospitalizations in the prior six months and multiple chronic conditions - with intensive care-management services in the months following hospital discharge. A team of nurses, social workers, community health workers and health coaches, supported by real-time data of healthcare use, perform home visits, accompany patients to doctor visits, and help patients enroll in social-service programs. This approach aims to improve the self-sufficiency of patients in navigating the healthcare and social-service systems and has the potential to reduce hospital use and improve patient well-being. This project will rigorously investigate the impacts of the program on subsequent healthcare utilization and the use of social services through a randomized controlled trial.
This project studies a program for 'super utilizers' of the health care system - individuals with chronic diseases and frequent hospitalizations. It tests whether the program of providing intensive care management after discharge from the hospital increases the use of social services and ultimately reduces hospital re-admissions, reduces overall healthcare costs, and increases employment.
