After years of positive attention from the media and public health leaders, an expert study has challenged the effectiveness of one aspect of a program developed by the Camden Coalition of Healthcare Providers to benefit patients with complex medical and social needs.
Researchers at the Massachusetts Institute of Technology who study poverty examined the coalition’s work to reduce hospital readmissions by deploying care teams to help high-needs patients navigate the system after their discharge.
Their findings, published in the New England Journal of Medicine last week, show the intervention failed to reduce the number of patients who returned to the hospital in the following six months, when compared to a control group.
Coalition leaders and other experts emphasized that the results should not be considered the last word on this work, which has evolved over the years and grown into a national movement dedicated to improving outcomes for challenging patients and better controlling medical spending.
“It would be premature to judge from one trial examining one outcome whether the Camden Coalition model should continue or how it can be strengthened,” said Rutgers professor Joel Cantor, director of the Center for State Health Policy, who has worked closely with the coalition. “To achieve those goals, much more work remains to be done.”
Barriers to coalition’s health goals
The researchers, at MIT’s Abdul Latif Jameel Poverty Lab, or J-PAL, stressed that the very nature of these patients’ medical and social needs made it hard for the coalition to achieve its goals. The randomized trial included nearly 800 patients treated between 2014 and 2017 for multiple, diverse and complex conditions; 40% reported substance abuse issues, and all took at least five daily medications. Half lacked a high school diploma, 95% were unemployed and some were homeless.
“This study confirms what our care teams see every day — care management that focuses solely on health care is insufficient,” said Kathleen Noonan, chief executive officer of the Camden Coalition. “People with lifetimes of trauma and complexity are best supported by high-quality resources in the community and a health care environment designed to meet their needs.”
While the research focused on the coalition’s original Camden Core Model, which dates to 2007, Noonan said her staff is reviewing the study closely to see how it can help their work in the future. The coalition — created under the local stewardship of Dr. Jeff Brenner, who went on to win a MacArthur Foundation “genius grant” — has welcomed outside review of its work, choosing to work with J-PAL to evaluate its efforts in 2014, and regularly updates its approach to integrate lessons learned, program leaders note.
“We’re undertaking ongoing analysis to provide more insight to help us shape our future work, [and] we do so knowing that the next iterations will have their own setbacks and successes. We welcome that,” Noonan told NJ Spotlight.
Coalition staff has already identified two “major lessons” from J-PAL’s randomized trial, which split the 800 participants into two groups, one of which received coalition team visits. The research showed at least six out of 10 patients from both groups were readmitted to the hospital within six months.
“First, we learned that the work we do requires a broader range of metrics. Readmissions is very important, but our programs have broader goals than that,” Noonan explained.
Cantor, with Rutgers, agreed this is an important metric, but not the only measure of success.
The J-PAL study wasn’t designed to assess other findings, although researchers did notice an uptick in enrollment in a federal nutrition program for low-income residents among the group that got coalition attention.
“Second, when serving people with medical and social complexity, care coordination alone isn’t enough. It must be paired with strong community networks — including social services, behavioral health, public health, community-based organizations and government agencies,” Noonan added.
J-PAL researchers also found that the very act of intervening with these patients — through home visits by trained coalition staff and doctors — proved difficult, given hardships like unstable housing or limited phone service. Only one quarter of the time were these teams able to meet the goal of connecting with patients within a week of their being discharged from hospital.
“Our results suggest that there are challenges for super-utilizer programs aimed at medically and socially complex populations,” the researchers wrote. “It is possible that approaches to care management that are designed to connect patients with existing resources are insufficient for these complex cases.”
When Brenner — who now oversees national complex care programs for UnitedHealthcare — first brought Camden’s health leaders together to form the coalition, just 1% of the city’s patients were responsible for 30% of its health care costs. Many of these patients were visiting local emergency rooms for routine care and suffering from complications related to treatable, or even preventable, diseases.
The group convinced hospitals to pool their data and used that to identify patients considered “frequent flyers” at emergency rooms and target them for additional care. The process, dubbed “hot-spotting,” was featured in a 2011 New Yorker magazine article. But it didn’t take long for Brenner and others to identify weaknesses with this Camden Core Model — and look for ways to improve their work.
“The story of the Camden Core Model’s evolution is testament to our willingness to iterate and change based on what we learn,” the coalition notes in a history of its work, published last summer. “We have yet to discover the full set of solutions that guarantees better health and well-being.”
By 2012, the coalition had entered its second phase, according to the publication, which included an effort to better target patients who could benefit more from its interventions. As a result, it no longer focuses on individuals in nursing homes and those with cancer. The group worked to become more proactive, using its data in real time, and sought to connect patients with a primary care provider who could act as a “medical home.”
Within two years, the coalition had built on this concept with a program designed to connect discharged hospital patients with a doctor for follow-up care within seven days of discharge, to help reduce readmissions. The coalition added psychologists to its care teams and launched its Housing First program, to ensure patients had safe homes. The group also became one of three (now four) accountable care organizations (ACOs) under an Affordable Care Act initiative designed to better coordinate care and reduce costs.
In recent years, the coalition has worked to solidify partnerships with other social service providers, launching a legal clinic with help from Rutgers University to help patients address barriers to housing and other services. And, with its fellow ACOs, the coalition is advocating for a revised model that expands its work geographically as a regional “health hub,” which it hopes can serve more patients with serious needs.