In one of the poorest cities in the United States, Dr. Jeffrey Brenner is spearheading an innovative approach to primary care, using health data to identify hospital frequent flyers and deploying teams of nurses and health coaches to get patients’ health – and health care costs – under control.
His work in Camden, N.J., has been slowly drawing attention from health policy experts around the country. And it got a big boost in September when the MacArthur Foundation named him one of its 2013 fellows.
Dr. Brenner, a family physician, joins 23 others – including artists, scientists, and economists – who have been honored for their contributions to "American creativity." Each of the fellows will receive a "no strings attached" stipend of $625,000 to be paid out over 5 years.
The MacArthur Foundation singled out Dr. Brenner's work in founding the Camden Coalition of Healthcare Providers and called his approach to health care delivery "an important contribution to the national conversation on health care reform."
Data are key
It started in 2002 when a small group of Camden-area primary care providers started meeting for breakfast to share their frustration with the barriers they faced in practicing medicine in a fragmented, inefficient system. Fast forward a year and the group had grown to include nurses, physician assistants, podiatrists, and more. They soon formed a nonprofit organization – the Camden Coalition of Healthcare Providers – to tackle some of the systems issues they all encountered.
Photos licensed under a Creative Commons license. Courtesy of the John D. & Catherine T. MacArthur Foundation
Dr. Jeffrey Brenner outside his closed family medicine practice in Camden, N.J.
It took a few more years, but Dr. Brenner, who had signed on as executive director, eventually succeeded in getting to what the coalition members saw as the key to breaking down the silos of care: health data.
Today, the coalition operates a health information exchange that includes patient-level claims data from all three of Camden’s hospitals. They have real-time access to admission and diagnosis information for every Camden resident. Using that data, they target patients who need extra social and medical support.
Here’s how it works: the coalition receives a data feed on hospital admissions each day. Staff members identify the patients most in need of support and deploy a team of nurses, social workers, and health coaches to meet with the patient at the bedside. If the patient enrolls with the coalition, the next step is a home visit at discharge for medication review, but also to ensure that the patient’s home and social service needs are met. A team member accompanies the patient on follow-up visits to the primary care doctor and on specialist visits.
"We stick to them for about 90 days," Dr. Brenner, 44, said in an interview. "Then we graduate them."
The idea is to heap resources on the patients whose complex medical needs and lack of social support land them repeatedly in the emergency department, when what they really need is high-quality primary care. The Camden data demonstrate the realities of American health care: a small group of patients use most of the health care resources and cost the system money. In Camden, about 90% of the cost of hospital and ED care is spent on 20% of the patients, according to coalition data.
For patients who want to break the cycle of uncontrolled chronic disease and frequent ED visits, the coalition’s approach can make a big difference, Dr. Brenner said.
"If a patient is tired of being sick and tired you can go from 20 [hospital] visits to none," he said. The tricky part is how to help patients who aren’t primed for change and don’t trust the system. How to reach these patients is a problem they continue to work on in Camden and in other cities around the country. The coalition is working with organizations in Allentown, Pa.; Aurora, Colo.; Kansas City, Mo.; San Diego; and six other communities to adapt the Camden model.
Industrializing health care
One of the biggest problems the coalition has run into, and that others are finding around the country, is that once they identify patients who want to make changes in their health care, there aren’t enough well-run primary care practices to take on their care, Dr. Brenner said.
Even certified patient-centered medical homes don’t always do enough when it comes to incorporating clinical care teams, relying on health data, and reaching out to complex, recently hospitalized patients, Dr. Brenner said.