Last week, I spoke with Jeffrey Brenner, M.D., executive director of the Camden Coalition for Healthcare Providers, a 10-year old effort in the New Jersey city that brings together the city's three health systems along with physician groups and other providers to coordinate health care outreach and services. It's a fascinating effort that has received attention from Atul Gawande, among others, and all the more remarkable when you consider that Camden, with a population of a little over 77,000, is one of the poorest cities in the United States.

I was talking to Brenner for an article I'm working on for an upcoming print edition of H&HN about the challenges hospitals face in treating the small group of patients who utilize the lion's share of health care resources. According to a recent AHRQ report, the 1 percent of patients at the top of the utilization pyramid accounted for roughly one-fifth of all health care spending in 2009, or over $90,000 per person.

Among the Coalition's care coordination activities, which include a diabetes collaborative and a violence intervention program, is a care management effort aimed at reducing ED over-utilization. The five-year-old effort leverages the work of a multidisciplinary outreach team, which works with patients to develop a long-term medical home. The team, which includes a nurse practitioner, a social worker and a medical assistant, works with patients in settings that include homeless shelters and Camden street corners.

The program is supported by a health information exchange, launched in 2010, with the capability to receive near real-time information on patients admitted to the city's three hospitals each day. The coalition then uses that information to help arrange primary care visits and other care coordination services for admitted patients.

"We go and see patients within 24 hours of being admitted," Brenner says. "That's a real time feedback loop."

The team learned that many, though not all, "superutilizers" are homeless; others have difficulty accessing transportation or poor social relationships. Generally Brenner said, high-utilizers fall into one of three categories: elderly and disabled patients, isolated and often homeless patients with a variety of social barriers to care and patients with primary care providers who are still receiving inadequate care.

"It was like sending a deep space probe out into the delivery system," Brenner says. "[High utilizers] turn out to be a mirror you could hold up to the entire health care system."

Each group needs a different approach, Brenner said. But while there are generalities to be extracted from the data, Brenner stressed that providers still have to work at the face-to-face level to truly engage patients and identify potential problems and barriers.

For instance, Brenner related the story of an elderly patient who was having difficulty controlling his diabetes. During a site visit to his apartment, the care team watched as the man filled his syringe for his daily insulin shot with air. It turned out the man was also sight-impaired, Brenner said, and needed assistance with his shot.

I asked Brenner how the hospitals and health systems in the Coalition were impacted financially — after all, in a volume-based system, reducing utilization can mean a reduction in revenue. In Camden, though, the vast majority of patients are on either Medicare or Medicaid, meaning that the hospital members of the coalition were already losing money on their visits.

Ultimately, Brenner said the care coordination insights the Coalition discovers can be used, with modifications, on any patient population, Brenner says.

"We started with a group that no one wanted," Camden says. "But it turns out that if you're good at caring for homeless schizophrenics… you're also going to be good at caring for suburban baby boomers."

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