Against all Odds

FOCUS Multicultural Healthcare, March 2009, Volume 5, Issue 1

Family practitioner Jeffrey Brenner, MD, is working to reform the Camden, NJ, healthcare system one patient at a time.

Family practitioner Jeffrey Brenner, MD, is working to reform the Camden, NJ, healthcare system one patient at a time.

The street signs change quickly moving south along Broadway. Ferry Avenue quickly transitions to Emerald and Viola streets, but little else in the landscape changes. Block after block, the rundown homes and boarded-up storefronts stare back at passersby; mere skeletons that once housed a thriving populace of 140,000, now virtually cut in half.

The city is Camden, NJ. The median household income in 2005 was $18,007, compared with a state average of $61,672. The average resident is 27.2 years old. Anyone with the wherewithal to move out, does so. Poverty is rampant; drug use is prevalent.

A farmer’s market along Mt. Ephraim Avenue is well-stocked with fresh fruit and produce. Literature is distributed to residents in an attempt to educate on the benefits of healthy eating. Several blocks away, two street vendors position their carts about 20 feet apart. Walk-up business is thriving at the cart selling fast-food and snacks; the other vendor’s bountiful selection of fresh fruit goes unnoticed.

The healthcare delivery system in Camden is in chaos. The emergency rooms of the city’s three hospitals are abused. They have become the primary care office of choice for many residents. According to data compiled by the Camden Coalition of Healthcare Providers, emergency room utilization in 2003 was twice the national average. High utilizers abound; 9% of patients who visited the ER four or more times accounted for 28% of the visits, with 20% of the patients responsible for 90% of the costs, or approximately $10 million a year to care for the 1,000 highest utilizers.

“It’s sort of mind-boggling what we’ve done,” says Jeffrey Brenner, MD, clinical instructor, head of the Division of Urban Health for Cooper Family Medicine, and a family practice physician in Camden. “We’ve built a hospital system and a specialty care system on steroids. And we’ve built an anemic and shriveled primary care system. Our system is so un-patient centered that patients are meeting their needs the only way they know how, which is to go to the ER over and over.”

Rise of the Coalition

Sitting in his office across the street from Cooper University Hospital, Brenner laments that practicing medicine anywhere today is frustrating. But practicing medicine in a Medicaid environment is even more challenging. “I felt a personal mission to provide care in this environment,” he says, “but you just feel like you’re beating your head against the wall all the time.”

Five years ago, Brenner gathered his Camden healthcare peers for breakfast meetings. The meetings proved cathartic, and it soon became clear that the issues Brenner faced in his practice were shared by his fellow practitioners. The meetings became regular, and soon thereafter evolved into the Camden Coalition of Healthcare Providers, comprised of physicians, nurse practitioners, social workers, school nurses, healthcare administrators, and other individuals dedicated to improving the health status of all Camden residents.

Accomplishing that daunting task, however, required ammunition in the form of healthcare data. Such data at the community level is rare.

“We all felt, at a personal level, that healthcare delivery in poor communities is fragmented and completely disorganized, and that we could do a better job,” says Brenner. “But in order to make that case, you first need to collect a really good picture of the current status. Collecting good health data was going to be the linchpin to the success of this project.”

The Coalition started with Cooper University Hospital and was able to obtain the name, address, date of birth, date of admission, date of discharge, diagnosis codes, charges, and receipts for every Camden city resident over a 1-year period. The same information was then obtained from the city’s two other hospitals—Our Lady of Lourdes Medical Center, and Virtua Health Camden. Data from the three hospitals was linked, then widened to a span of 5 years. The result was a very robust snapshot of the health of the city.

“If you say asthma, I can tell you what the cost is over a 5-year period,” says Brenner. “I can tell you the rate of asthma for specific neighborhoods. That’s a very powerful thing to be able to do.”

Using the data

Brenner explains that the best way to think about the data is as though you were an advertiser, and advertisers segment data into natural groups. The Coalition segmented the population into ER utilization categories: the super utilizers, who annually frequent the ER 30 or more times; a middle group; and a group who come once or twice a year.

“We realized it was going to take very different interventions to deal with each of those groups,” says Brenner.

For example, at the low end of the spectrum are those who use the ER infrequently. They need improved access to acute care, so that when their child is ill, they can get care when and how they want it. Those in the middle group are a mix of people struggling to control a chronic disease. They require a different kind of primary care. The problem, says Brenner, is that primary care is designed in an episodic fashion.

“I’m paid to sit in my office and see patients,” he explains. “But the most dysfunctional people in my practice are all sitting at home, depressed, getting sicker, not taking their meds and getting foot ulcers, while the worried well are the people filling up my office all day.” Fixing the problem, he adds, is “going to take a fundamental transformation of the way we design and fund primary care.”

The super utilizers represent the ultimate challenge. These patients require the efforts of an elite team of healthcare professionals who know how to work with and reach out to them. Nine months ago, the Coalition began building a care management team comprised of a nurse case manager, a community health worker, and a social worker. The original vision of using a traditional telephone model for reaching out to these patients quickly went by the boards. Many of them are homeless; others don’t have phones.

“These patients have a bad health habit called ‘overutilizing the ER,’” says Brenner, who refers to the treatment the care management team provides as transitional primary care. “It’s going to take a much higher touch and a much closer intervention to be able to change that. We have to get them re-engaged in the medical system, and re-engaged in a comprehensive care model. Only then can we begin to move them into the normal care delivery system.”

Easier said than done

While some patients may have one or two barriers to care, those in the super-utilizer category possess all 20 barriers. They are simultaneously challenged with homelessness, mental illness, language barriers, substance abuse, and low literacy, and they often have a wide range of physical limitations. They are the antithesis, says Brenner, of a healthcare delivery system that has ingrained default assumptions.

The system, he explains, assumes an individual is employed, insured, middle class, English speaking, and literate. If any of those assumptions don’t hold true, the delivery system fails. If multiple assumptions prove invalid, the failure rate is even higher. “And these patients are the most extreme version of that.”

Before the care management team could see patients, however, two tasks remained: buy-in from the local healthcare delivery system, and patient identification. Toward those objectives, the Coalition invited social workers to a city-wide meeting. They came, and so did emergency room doctors and hospital-based physicians. All were familiar with the super utilizers, and all were frustrated and tired of providing patchwork solutions to this group.

“One week, the patient ends up meeting with an eighth floor social worker at one hospital, the next week they’re over at another hospital, and the third week they’re on the sixth floor back at the first hospital,” explains Brenner. “[The super utilizers] confound the system we’ve created, so people came to the table because they saw this project potentially making their job easier. And that’s what a coalition should be about, making everyone’s life and job easier.

” With the buy-in came patient referrals from social workers, emergency room doctors and hospitalists—about 10 patients a month, and the care management team now addresses the needs of a roster of 60 of the sickest, most dysfunctional people Brenner says he has ever interacted with.

“The nice thing about having a city-wide approach is we get called right away when one of our patients hits one of the ERs,” says Brenner. “The docs know who we are, and they find it easier to interact with us in helping to co-manage the patient. We go to the homeless shelter, transit center, a street corner. Wherever these patients are, we track them down.”

Reaching out

Kathy Jackson, a nurse practitioner and member of the Coalition’s care management team, maneuvers her car through the Camden streets, making her ‘rounds’ on a steamy July afternoon. She acknowledges the rewards of her job, but also recognizes the extreme difficulties.

Patients who have mental health issues are resistant to treatment; those with substance abuse problems live in denial. “But,” she says, “as healthcare providers we have to try to help them look at another way of living their lives. It’s very hard for them to access the system. [Reaching out] is a way to kind of help that situation.”

Her first stop today is a visit with David, a middle-aged African American with type 2 diabetes, hepatitis C, and cirrhosis of the liver. Within the past year, David was told he has cancer. Still, David smiled often during the visit and was surprisingly upbeat.

“I’m over the initial shock [of learning of the cancer],” David explains. “The doctor gave me a little more time. He said I gotta give up some things, but that’s the price you pay to see your grandkids grow up.”

Jackson reviews David’s medications with him, reminding him about the possible side effects, then takes a recent history of his health and the doctors he’s seen. The visit ends with a hug, and David smiled once again, then laughed. “These guys are more worried about me than I am,” he says.

Next was a visit with Vincent, 6-foot-5 and weighing in excess of 400 pounds. Vincent has COPD and sleep apnea—and a smile as broad as his girth. He lives in an upstairs bedroom of an abandoned two-story house, most of which was charred in a recent fire. The bedroom has heat in the winter, air conditioning in the summer, and a small refrigerator for food storage.

Jackson sits with Vincent on the front porch and reviews his medications and eating habits. “Drink a lot of water,” she says, then tells him his good cholesterol was a little low during his last check. She suggests walking a little more and watching the amount of fat in his diet.

Vincent nods in agreement. “I make all my [doctor] appointments,” he says. “And if I’m having pains, these guys come around and check on me and make sure my heart and everything else is good.”

This visit, too, ends in a hug. “My staff end up almost feeling like their role is to defend the patients against the chaos of the health system,” Brenner explains. “They get very attached to the patients, and the patients get attached to them. The only reason anyone ever changes their health behavior, and this is true for all of us, is because someone you love told you over and over to modify something you’re doing. So, we provide them with very clear structure in the way of accessing the system, with wrap-around services, and we do it in a compassionate way where people start to change their behavior. It’s not rocket science, really.”

Positive early results

If early results are any indication, many of the patients involved in the program are, in fact, changing their behavior. Of the 92 patients in the program, 35 have been involved long enough—and had a prior history in the project’s database—that early evaluations of the project’s effectiveness are possible. Those 35 patients averaged 18.1 inpatient hospital visits per month prior to becoming involved in the program. The number of visits has since dropped to 7.9, or a 56.6% reduction. Similarly, emergency department visits declined 32.6%, from 43.5 to 29.4 visits per month.

“It’s extremely satisfying and very gratifying,” Brenner says. “It’s proof of what I’ve always known. If you meet people’s needs and provide them with care, they will heal and get better. And in the process, they will cost society dramatically less money.” Along those lines, hospital charges per month for the same 35 patients declined by 56.3%—from more than $1.2 million per month to just over $530,000 per month. “We’re not doing anything magical with these folks. We’re building relationships with them, getting to know them as people, and finding out what their needs are.”

The patients, in particular the super utilizers, are also building relationships—with each other. Brenner explains that two of the super utilizers, both men in their 50s, have become buddies and recently moved in together. Both men are on long-term disability and are pooling their money. They accompany each other to their medical appointments, and as a result, have gotten a lot healthier. “It’s a fascinating outcome and something I never expected,” Brenner says. “A light bulb has gone off in our heads, and now we’re getting ourselves wrapped around the idea that the cure for super utilizers is other super utilizers. We’re going to start a patient support group for our super utilizers. Who else can understand a 55-year-old, chronically ill, homeless person who has been to the ER and hospital 50 times a year but someone else just like them? Now, we have to figure out how to build on what we’ve stumbled onto.”

Connectivity and collaboration

Brenner and the Coalition have also developed a Web portal aimed at getting Camden physicians to adopt health information technology and thereby improving care coordination in the city. At present, says Brenner, a problem exists between what’s being done by the primary care physician and what’s being done by the specialist, and coordinating what those two roles are.

“For example, if I have a patient who’s newly diagnosed with hepatitis C, if they’re illiterate, or Spanish speaking, and I send them up to see a gastroenterologist, they don’t understand anything the gastroenterologist said,” Brenner explains. “They walk out with all these scripts for tests they have to get. They get sort of overwhelmed by the whole thing and they don’t get any of it done, or they get a little of it done, and then they come back to see me and I ask if they went to see the gastroenterologist, because I may not have gotten a letter from the gastroenterologist. The whole thing is just chaos, it’s disorganized. It’s a waste of time and money. If I can send them to the gastroenterologist having all of the workup done ahead of time that the GI wants, then they go for one visit, they get a decision about treatment, and they’re done. But we don’t do any of that.”

Brenner compiled an online list, specialist by specialist, of the tests and procedures each physician would want a new patient to have done. The list also contains the email addresses of all the GI docs, their fax numbers, and a cover sheet.

“I’ll literally hand this to my staff, who in turn [will] inform the patient about the tests,” Brenner says. “They staple the results together, fax them to the specialist, and the patient gets a much more organized care delivery product. This is where the medical home idea needs to move. We’re a long way away from this, but that level of coordination should be going on all the time.”

Brenner adds that everything he and the Coalition have done so far is a scalable blueprint that can be used by any city in the country. The Coalition has been backed by a $300,000 grant from the Robert Wood Johnson Foundation, and some funding from other organizations, but the real key ingredients are time and dedication.

“For $2,000 [in software programs] and some sweat equity, you can build a citywide database,” he says. “The citywide database was built in my free time and other people’s free time. We didn’t build this with a grant.”

A major juggling act

Brenner talks about balancing his family practice with running the Coalition and his responsibilities to Cooper University Hospital as being “a total nightmare.” Last November, his practice nearly went bankrupt, and he had to lay off a full-time physician assistant.

“Medicaid reimbursement rates, in some instances, are falling, and my practice has always had a healthy mix of privately insured patients and Medicaid patients,” says Brenner. “But then that started to tip over. Literally, it was getting down to where the line of credit couldn’t go any higher, and I wasn’t going to be able to make payroll. Lying in bed at night worried about making payroll is a pretty lousy place to be.”

With so many obstacles, why does Brenner continue to push onward? The 39-year-old physician pauses a bit to contemplate that question. “What we’re doing [in healthcare delivery] right now is so wrong,” he says finally. “Unless some people stick their neck out and push for improvements, for a better way, we’re just going to keep doing the same thing. I would rather leave medicine than stop doing what I’m doing, frankly.”

So Brenner continues to battle. He recently relocated his practice, which was situated between a sneaker shop and a check-cashing store, to the lower level of a charter school several blocks away. “It’s a nice environment; it’s easier for my patients,” Brenner explains. “Check-cashing places attract lots of people pan-handling. Literally, there would be crowds outside my office pan-handling.”

Brenner acknowledges that an element critical to the success of the work he does is the support he receives from his wife, Jenny, who is a city planner by training. “There’s some synergy between the work she does and the work I do,” he says. Jenny works for Cooper’s Ferry Development Association, which has been responsible for many of the redevelopment efforts along Camden’s waterfront, and is now providing a lot of technical assistance in the neighborhoods. “She’s doing the buildings and I’m doing the people,” Brenner says, smiling. “And you know, her work is just as hard as my work in many ways. We have a lot of stories to share.”

Looking ahead

Brenner says that the key to the Coalition’s work going forward is the redirecting and reallocating of money away from specialty care and hospital care and into primary care. And Medicaid at a national, state, and local plan level needs to make that decision.

“Until they invest significantly in the infrastructure of primary care, not just pay more for primary care, but a profound reinvention of how we deliver primary care to create patientcentered medical homes, none of this is going to change,” says Brenner. “What you learn about Coalition building and this kind of work is that it’s not a sprint, it’s a marathon. It’s going to take 20 or 30 more years to pull this off.”

Is he in it for the long haul?

“I think to do really good work somewhere you have to stay in that place for a long time,” Brenner explains. “I mean, it’s really easy to jump around. America is all about defining your career, and I could jump around if I wanted to. You jump around, you climb up ladders, you get bigger titles and bigger salaries—it’s pretty easy to do. But I don’t think you accomplish as much.”

Ed Rabinowitz is a veteran healthcare journalist based in Bangor, PA.