The Breakfast Club: A Healthy Start to Community Coalitions
This article originally appeared in the National Council Magazine.
An interview with Jeffrey Brenner, MacArthur Fellow and Executive Director, Camden Coalition of Healthcare Providers
The Camden Coalition of Healthcare Providers is a nonprofit formed to improve the quality, capacity, and accessibility of the healthcare system for vulnerable populations in the city of Camden, New Jersey. Founder Jeffrey Brenner found that in Camden, 80 percent of the costs were spent on 13 percent of the patients, and 90 percent of the costs were spent on 20 percent of the patients. He wanted to address this disparity through a collaborative community approach. He started the Coalition and built relationships across the Camden healthcare provider community — from community-based private practices to front line hospital staff to social workers across the city. Using those relationships and guided by the Camden Health Database to inform and evaluate, the Coalition operates several health initiatives to demonstrate a collaborative approach to improving care delivery and patient outcomes. The program models can be replicated and implemented in other cities across New Jersey and the country to result in improved patient care and reduced costs. The Coalition has also built relationships with the executive leadership of local hospitals, social service/public health agencies, state government agencies, Medicaid health plans, and policymakers to advocate for legislation to sustain this modern day approach to healthcare delivery.
National Council: What does care coordination really mean?
Brenner: The words care coordination and care management have been really rendered meaningless, and they’ve been loosely applied to different models. For us care coordination and care management mean data-driven interventions that focus on patients with significant needs or in crisis. And it involves intensive relationship building, face-to-face interaction, home visits, accompanying patients to appointments, significant training in harm reduction, trauma-informed models, and motivational interviewing.
National Council: Who needs to come together to make all of this happen?
Brenner: Complex patients touch so many different parts of the healthcare system that it doesn’t work to just have one stakeholder. A complicated patient moves from hospital to hospital, emergency room to emergency room, and sometimes primary care office to primary care office. They can even move through different insurance companies. They have interaction with long-term care, sub-acute care, durable medical equipment, visiting nurses, hospice… It becomes enormously challenging to figure out how each entity by itself is going to make the relationships work. It calls for an umbrella approach at the community level that pulls stakeholders together and aligns them around the workflows and service delivery models.
National Council: For the Camden Coalition, it was you — as the primary care practice — that took the initiative to reach out to other stakeholders, right?
Brenner: Yes. I was a practice primary care doctor by myself in a three-exam room office, incredibly frustrated every day by how disorganized and fragmented the healthcare system was for my patients. And I spent a lot of hours on the phone and a lot of time to try and make the system work for people, but you can only stand in the gap by yourself for so long and it’s not a stable way to fix the system. So I began to pull people together for what we called the Health Provider Breakfast Group. It was literally a group of solo practice providers getting together having breakfast quarterly and eventually we formed the non-profit Camden Coalition. We brought the hospitals and the rest of the alphabet soup to the board of the organization as a way of collaborating.
National Council: So really, anyone can take the initiative to bring the community together?
Brenner: It takes humility, it takes patience, it takes fortitude. It takes playing for the long term and not getting discouraged in the short term. It takes data sharing, and I think data is a way of pulling people together.
It takes lots of little wins. So think about what’s the smallest little win you can have tomorrow and don’t play just for the big wins. Community organizing is a skill that very few people in the health profession have any knowledge of. That’s really the technique we’ve used in organizing the community of healthcare providers and institutions.
And it also takes a lot of taking one-on-one relationship building to generate real collaboration. For example, a hospital is like a small city — made up of 5,000 employees who can become engaged and excited supporters. But just because you meet with the CEO doesn’t mean you’re collaborating with the organization. Just because the mayor’s excited about what you’re doing doesn’t mean the city council and the department heads and the chiefs and the vice presidents are excited as well.
National Council: At Camden Coalition, you say your mission is to help reduce costs and still deliver quality service. How do you do that?
Brenner: The vision is for Camden, NJ, to be the first city in the country to bend the cost curve and improve quality. And that’s really a breakthrough concept — if you can do both of those things then it’s a game changer in healthcare. And if you can do it for one person you can do it for five, you can do it for ten, you can do it for fifty, a hundred, and in the end do it for thousands, which can generate millions of dollars in savings. This is our hypothesis.
We think the biggest preventable costs are unnecessary hospital admissions. So we’re focused like a laser beam on reaching every hospitalized patient to keep them from coming back. Because we think that if you’ve been to the hospital, twice in six months, you’re the exact subgroup that is in crisis. If you focus on every hospitalized patient with a defined workflow for when they leave the hospital, it’s an incredible opportunity to save money. Each hospitalization is $10,000. Every hospitalization should be considered a failure of the healthcare system until proven otherwise.
Every hospitalization should be considered a failure of the healthcare system until proven otherwise.
National Council: Are there other ways you look at cost reduction? An NPR story on the Camden Coalition described how you work like the airlines — overbook to avoid no-shows, etc.
Brenner: Yes, there’s a lot of task shifting that can be done. There are many things that doctors do that they don’t need to do. We try to get doctors to delegate work to nurses, nurses to delegate to Licensed Practice Nurses, and LPNs to delegate to health coaches. Much work can be shifted to lower cost employees. This requires protocolization, standardization, and training, and you can’t do those things unless you create a highly structured system to support it.
National Council: How do you pay for these improvements?
Brenner: Most of our services are grant funded, which is not a stable structure in the long term. We do have one contract now with United Healthcare. They’ve been great partners, very innovative, and now have an upfront payment for services we provide with a back end savings payment. But there needs to be a lot more work on payment reform.
I don’t know that we need more money, we need to just spend the money we have better. Let me give you an example. In New Jersey, care management services are being delivered telephonically — nurses in cubicles are trying to call homeless people with no phones! New Jersey spends about $38 million a year with 700 FTEs in cubicles. A small amount of that money moved into a community-based model could achieve a lot more.
National Council: You are focused on high emergency room users, but can your learnings be applied to other populations using healthcare as well?
Brenner: Of course. Our whole idea for how we deliver services came from behavioral health, it came from a visit that I had with an Assertive Community Treatment team — they knocked my socks off. I was so impressed with the model and thought, why isn’t the medical side doing something like this? I’ve also been really impressed with PACE, Program for All-Inclusive Care of the Elderly, which is a similar model with wraparound services for dual eligible, high-risk geriatric patients that should be institutionalized but are being kept in the community.
We’ve been heavily influenced. Rarely do people invent totally new ideas, innovation is just grabbing good ideas and twisting them into new combinations.