Camden, New Jersey has high hospital readmissions rates: both hospitals accepting inpatients in the city limits paid steep CMS penalties in 2012, reducing their penalties for fiscal year 2014 by only .05 percent. Camden also struggles with preventable admissions, unnecessary emergency department visits and distribution of healthcare access. Things would seem completely 
bleak, were it not for the fact that Camden is emerging as one of the most innovative places for healthcare in the entire nation. For that, the city has The Camden Coalition of Healthcare Providers, and in particular Jeffrey Brenner, MD, to thank.
Dr. Brenner is a primary care physician whose passion in life is to create a healthcare model to meet the medical and social service needs of the most vulnerable citizens in impoverished communities in Camden. He recently won a MacArthur fellowship for his work in employing cooperative care to expand preventive care and reduce unnecessary healthcare use.
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Dr. Brenner began his career in Camden as a private practice primary care physician. Camden is the most dangerous city in the country, and it was also the most dangerous city in the country at that time. "I was overwhelmed by what I was seeing [at work]. The official crime statistics were severely underreporting the true rate of crime in the city," he says. "One thing about Camden is every time you think you've seen it all, it can always get worse. Every system here can fail more than you can ever imagine."
So he enlisted the help of a medical student to look at billing data from the city's hospitals to uncover more accurate rates of trauma in the city. What they found went beyond trauma care. Their billing data analysis showed the census track aged 14 to 24 years had a rate of hospital admission of 1 in 19 in a one-year period. The national average for that rate is 3 in 10,000. Ultimately, this result led Dr. Brenner to pioneer the use of billing data to understand broader patterns of health utilization in Camden. By mapping the locations of patients from the billing data, he was able to discover where care was needed most.
Within weeks of starting the geographic mapping database, he began to realize there were quite a few patients in the dataset he knew well. He suspected the system was failing them. "It was an underfunded, undercapitalized, poorly run, slow-motion failure that was filling beds unnecessarily," he said. "I could see it right in the data, could feel it in the office. Hospitals were expanding emergency rooms and hiring more specialists, yet primary care offices in the city were boarding up and retiring."
In an attempt to improve preventive care for these most vulnerable patients, Dr. Brenner and his team began by calling patients individually, a standard approach to case management. But telephonic case management wasn't working. Follow-ups were scarce, and some patients were impossible to reach. "It was just nurses in cubicles calling homeless people with no phones," says Dr. Brenner.
So to understand the source of the problem, he did something rare for this day and age: he assembled a coordinated care team and went out to meet his patients through house calls.
"We spent a lot of time getting to know the one percent of super-utilizers," he said. "We started collecting data from a real-time feed from local hospitals, making lists of those who had been admitted and logging into their health records."
For some particularly problematic patients — those who seemed to be stuck in the system, admitted two or more times to a hospital in six months — Dr. Brenner went right to the bedside. He and a care team — made up of physicians, nurses, social workers and care navigators — would meet the patient, introduce the coordinated care program and make sure that patient met with a primary care physician within 48 hours of discharge. The team even helped patients apply for benefits. "Our goal was to graduate [patients] from this program in 90 days to a well-run primary care office," says Dr. Brenner.
Even with coordinated care for super-utilizers, the major obstacle to his goal of keeping the sickest patients out of the hospital, as Dr. Brenner has ascertained, is that the primary care visit is failing its patients. "We're all coming to recognize that our success in the last 50 years has also had a downside, which is that we haven't caught up to the complexity of care, and we don't know how to make sure every patient gets the right kind of care very day. Here in Camden we're seeing glimmers of functional primary care, but we all have a long way to go to figure it out," he says.
While The Camden Coalition's coordinated care model has taken off, leaving healthier patients wherever it is implemented, Dr. Brenner's story is also somewhat of a cautionary tale. The MacArthur fellowship comes with a hefty sum of money, and Dr. Brenner plans on using it to pay off the loans on his failed primary care office. "It really proves the point there's no business model for taking care of everyone every day," he says.
Despite the lack of a business model that fully supports the preventive model of primary care, Dr. Brenner is optimistic and believes the industry is finally realizing that fundamental changes must be made to better coordinate care throughout the continuum. "We're focusing on quality, focusing on how to improve hospital dangers, and we're realizing we have to use the same techniques across the healthcare system to make sure patients get the same care as we follow them," he says.
He is convinced the answer to standardization in the healthcare system is inexorably linked to political will. While a solution may not happen because of his patients, underrepresented as they are, he hopes the baby boomers will catalyze the rebirth of primary care. "Baby boomers have changed every system they've ever touched," he says. "They've changed marriage, retirement, education, birth. They'll change primary care. It wouldn't take much for changes in their preferences to collapse narrow hospital profit margins."
It is because of this, according to Dr. Brenner, that the hardest job in America right now belongs to hospital executives. "It's like being a steel company executive 30 years ago. The sooner that hospital executives embrace a broader philosophy of delivering care to everyone every day, the more successful they'll be in transitioning to the hospital business model of the future," he says. To hospitals that don't quite buy it? "My strongest recommendation for boards and executives is to take a field trip to a local Blockbuster video store and stand in front of it," he says.
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