Camden’s Targeting of Medical ‘Hot Spots’ Becomes Model for Other Poor Areas

Doctors combine mental and physical treatment with attention to other needs for patients who need the most care

Dr. Jeffrey Brenner
A grassroots healthcare reform that sprouted in poverty-stricken Camden more than a decade ago has grown into a budding national movement that could make a real difference for those with complicated chronic health needs, while also bending the cost curve.

Hundreds of primary care doctors, nurses, and other frontline healthcare workers joined academics, public policy experts, and philanthropic leaders in Philadelphia on Thursday for the inaugural conference of The National Center for Complex Health and Social Needs.

The center, spearheaded by the Camden Coalition of Healthcare Providers, formed last spring to unite groups working to deliver better care to some of the most vulnerable communities in the United States in ways that cost less and improve clinical outcomes. And the three-day [link: |“Putting Care at the Center”] conference is just the next step in an ongoing campaign to spread the gospel.

Thanks to a $1.3 million grant from the Aetna Foundation, announced Thursday, the center will begin to develop a comprehensive curriculum to help other providers craft more effective ways to treat underserved patients. In the years to come, staff at the center will work with local partners to help implement these goals around the nation.

“All healthcare is local, but there are some tenets to the strategies and data sets and thinking that can be brought together and utilized elsewhere,” explained Dr. Garth Graham, president of the Aetna Foundation. “Our goal is to look at how we train and bring others on board with that skill set.”

“For us, it’s really about amplifying what they’re doing,” he added.

The coalition, led by Dr. Jeffrey Brenner, a MacArthur Fellow and primary care physician in Camden, has become well-known for its use of data to help drive high-quality, comprehensive care and support services to some of the city’s poorest, sickest patients. The work targets medical “hot spots” and “high-utilizers,” patients who absorb significant clinical resources yet remain sick; research suggests that 5 percent of the population received 50 percent of the healthcare spending in 2014, according to the coalition.

But data is only part of the picture. The Camden Coalition’s success also reflects its focus on individual patients — and efforts to address complicated mental health, substance abuse, and physical health challenges without passing judgment. It also requires healthcare providers to collaborate with a growing network of social service agencies to coordinate housing, transportation, and other assistance for patients.

[related]While the Camden team has received national accolades for its work, it is not the only group employing this type of model. There’s the Nuka System of Care, a patient-centered group launched nearly 30 years ago by Alaska Native people, and Hennepin Health, an accountable care organization in Minnesota, among others. The National Center for Complex Health and Social Needs, funded by some $8.7 million from a trio of backers (AARP, Atlantic Philanthropies, and the Robert Wood Johnson Foundation), brought these efforts under a shared umbrella. The Philadelphia conference is the group’s coming out party.

“Our goal is to coalesce a field and movement for better care for people with complex health and social needs,” explained Mark Humowiecki, the director of national initiatives for the Camden coalition. “We’ve been collecting friends along the way for years,” he added, “and it’s reached a critical mass where this really has the substance of a new field.”

Humowiecki said the sold-out conference, which continues Friday, attracted some 500 people and has sparked a “tremendous spirit of excitement” among attendees. Driven by detailed data, participants from different regions and with diverse backgrounds have found common ground talking about how to reduce street homelessness, improve home care, and better assist first-time mothers, he said.

The conference, and the center itself, “provides a home for people who are doing groundbreaking work in their own communities,” Humowiecki added. “These are people that didn’t run in the same circles usually,” he continued. “The data was an invitation to a conversation.”

Conference sessions focused on applying this integrated data, coordinating with community organizations, and including an embedded attorney in any healthcare team to help patients untangle any legal disputes. These presentations echoed some of the Camden Coalition’s efforts to better integrate physical care, behavioral health, and other aspects of wellness to improve clinical outcomes, while reducing costs.

A group of state officials from nine different states, part of the National Governors Association’s focus on complex healthcare needs, shared their work Thursday and Geoffrey Canada, founder of the Harlem Children’s Zone, a comprehensive social reform effort built around education, was scheduled to speak Friday morning.

The event was sponsored by insurance providers Aetna and Horizon Healthcare Services; Health Research and Educational Trust, a national research organization; Sutter Health, a California non-profit that provides healthcare services; and Virtua, the largest healthcare system in South Jersey.