A Revolutionary Approach to Improving Health Care Delivery

The Challenge: Inefficient, High-Cost Care. Many people with complex health and social issues have high rates of emergency department use and hospitalization. Super-utilizers is the shorthand term for these high-cost health care users.

Super-utilizers are diverse—some may lack not only financial resources and health insurance but also an understanding of how to use the health care system. Transportation can be another hurdle. For these and other reasons, many super-utilizers have no source of regular, coordinated medical and social support services—the very thing they need for stable health.

Providing more effective, efficient care to these patients is one of the major challenges facing the health care system.

RWJF Grantee Jeffrey Brenner: From Neuroscience to the Streets of Camden, N.J. Jeffrey Brenner planned a career in neuroscience research. In preparation, he entered a combined MD/PhD program at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School.

But while in the program, the New Jersey native helped start a student-run community clinic and became increasingly caught up in the delivery side of medicine—including learning to speak Spanish so he could better connect with immigrant patients. "I was inspired by the work, and by a family doctor who was volunteering to help oversee the clinic," he says.

The upshot is that Brenner left the research program, switched to family medicine and in 1998, after completing a residency in Seattle, went to work as a family doctor in Camden, N.J., delivering primary care, babies, and, in general, whatever health care services were needed to Latino residents.

His office was on a forlorn street in an impoverished city that had one of the highest crime rates in the nation—not the kind of practice every young MD has in mind. But says Brenner, "It was my dream job."

Hospital Data: A Window into Health Care Use. Eager to help the troubled city, Brenner joined a commission to reform the Camden police department. As part of the work, he created a database of emergency department visits by crime victims and mapped crime by analyzing patient addresses.

Although the reform effort failed, Brenner realized he could use insurance claims to map health care use across the city. He spent three years developing a computerized system that collected data for all three Camden hospitals (Cooper University, Our Lady of Lourdes, and Virtua Health).

"The full dataset told an unbelievable story of wasteful, disorganized services. Somehow good doctors were going to work every day at good hospitals and delivering a very disorganized set of services," he says. "My patients were in those data. They weren't getting their needs met."

The database—which has now evolved into a health information exchange with a wealth of patient data available to all Camden providers—showed that:

• Nearly half of the city's approximately 77,000 residents were visiting an emergency department or hospital annually—most often for head colds, viral infections, ear infections, and sore throats.
• Thirteen percent of the patients accounted for 80 percent of hospital costs; 20 percent of the patients accounted for 90 percent of the costs.

It showed, says Brenner, "We could make a big difference in people's lives if we could figure out how to deliver more organized services that were easier for patients to use." He set about doing exactly that.

(For more about Brenner's use of data and other aspects of his Camden work, see the article "The Hot Spotters" by Atul Gawande in the January 24, 2011, issue of the New Yorker.)

The Solution: Patient Management. Brenner formed an organization dedicated to improving the care of Camden's vulnerable populations and through this nonprofit group—the Camden Coalition of Healthcare Providers—implemented a care model aimed at increasing coordination of services for Camden's super-utilizers.

The Robert Wood Johnson Foundation (RWJF) supported Brenner's care model with two grants (ID#s 56562 and 62061) awarded through its New Jersey Health Initiatives—which assists community-based organizations working to improve the health and health care of residents of New Jersey, the Foundation's home state. See the Program Results Report for more information on the project.

The heart of Brenner's care model is a patient management program to improve the transition of super-utilizers from the hospital to outpatient care and ensure they continue to get the medical and other services they need—so they don't end up back in the hospital. The program, which started in 2007, includes these key ingredients:

• The database identifies hospitalized patients with complicated medical and social needs.
• A care management team—consisting of a social worker, nurse, community health worker and health "coach" (an AmeriCorps volunteer who plans to go into medicine or nursing)—visits the patient in the hospital, reviewing prescribed medications, conferring with doctors and nurses, and helping plan the discharge.
• Team members visit the patient at home immediately after discharge and provide ongoing support for two to nine months, including connecting the patient to a primary care doctor, accompanying him or her to appointments, and helping line up needed social services. The goal is to leave patients with the ability to manage their health on their own.

(In 2011 Brenner's organization initiated a similar intervention to reduce the readmission of hospitalized patients who have a medically complex condition but a source of primary care and fewer social issues. A care transition team composed of a nurse and health coach works with these patients. With support from a third New Jersey Health Initiatives grant (ID# 69124), care transition teams are now assisting patients of two Federally Qualified Health Centers in Camden: CAMcare and Project HOPE.)

While Brenner's main purpose was to improve care, there is evidence that his model reduces costs. The first 36 patients averaged a total of 62 hospital and emergency room visits per month before the intervention compared to 37 visits per month afterward. Their hospital bill total fell from a monthly average of $1.2 million to just over $500,000—savings that benefit the federal and state governments in reduced Medicaid spending and the hospitals in reduced charity care costs.

"All of the rigor I love about science and data and solving complex, difficult problems is even more applicable to thinking about how to deliver better care to complex patients," says Brenner. "I think I've landed in a great place where I can use my love of science to make a difference in people's lives."

Expanding the Reach. The Camden Coalition of Healthcare Providers—of which Brenner is executive director—has an annual budget of about $5 million and about 50 employees, who care for about 125 patients. It is housed in the Institute of Urban Health at Cooper University Hospital. Other funders include Bristol-Myers Squibb Foundation, Centene Foundation for Quality Healthcare, Merck Foundation, Nicholson Foundation, state of New Jersey, and the federal government through the 2009 American Recovery and Reinvestment Act (commonly known as the economic stimulus act).

The number of patients served will increase as Brenner implements an expansion funded by a $2.8 million federal Health Care Innovation Award made in May 2012 to Cooper University Hospital. The three-year grant from the Centers for Medicare & Medicaid Services (CMS) will support additional staff for the care management and transition teams.

In addition, the coalition has created a program specifically to help the approximately 7,000 Camden residents known to have type 2 diabetes. Called the Citywide Diabetes Collaborative, the initiative seeks to increase the capacity of primary care practices to provide comprehensive care to diabetes patients, increase diabetes self-management education, and improve coordination of care.

Brenner is also working to improve care beyond Camden:

• With funding from the Nicholson Foundation, he is helping coalitions in two other New Jersey cities—Newark and Trenton—implement his care model.
• He is providing technical assistance and training to four communities outside the state that are replicating the model under a CMS grant to the Rutgers Center for State Health Policy. The four are Allentown, Pa.; Aurora, Colo.; Kansas City, Mo.; and San Diego.

RWJF Perspective: "Dr. Brenner and the Camden Coalition of Healthcare Providers are tackling head-on the problem of uncoordinated and inefficient care that super-utilizers experience, and they are also developing collaborative strategies to improve the quality and efficiency of the local health care system," says Susan R. Mende, BSN, MPH, senior program officer at RWJF.

Brenner's approach dovetails with the work of Aligning Forces for Quality (AF4Q), RWJF's signature effort to lift the overall quality of health care in 16 targeted communities, reduce racial and ethnic disparities, and provide models for national reform. (The 16 communities include several entire states and regions as well as cities.)

In 2011, RWJF launched a $2.5 million, three-year initiative to develop super-utilizer interventions based on Brenner's model in six AF4Q communities: Greater Boston; Cleveland; Cincinnati; Humboldt County, Calif.; Maine; and West Michigan.

The initiative—Improving Management of Health Care Super Utilizers—includes the development and evaluation of local models plus creation of a Web-based guide for use by other communities. Brenner is providing technical assistance to the six communities and developing the guide and resource materials.

"The AF4Q communities are poised to leverage the Camden Coalition of Healthcare Providers' expertise to develop local interventions to improve care and reduce costs for their local super-utilizer patients," says Mende.

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