Getting It Right: On Building a Complex Care Network

The nation still lacks a strategy to provide cost-effective care for complex care patients. But one physician leader has built a NJ nonprofit that is making headway.

For all the advances healthcare has made over generations, the care of patients with complex needs remains firmly unchanged. In the view of Jeffrey Brenner, MD, a primary care physician in Camden, NJ, " We're still bloodletting people."

Brenner, a MacArthur Fellow, leads the newly formed National Center for Complex Health and Social Needs.

Its mission is to find cost-effective, coordinated strategies for complex care patients that take into account medical and personal needs, such as access to safe, affordable housing. Brenner spoke with HealthLeaders Media about the state of complex care delivery. The following is a lightly edited transcript.

HLM: You say complex care delivery is in disarray. How did we get to this point?

Brenner: We have a system of misaligned incentives and incorrectly trained professionals. We can transplant hearts and lungs, and cure cancer, but we haven't caught up to all that complexity.

There is a human side to all of this that we just haven't figured out. We have a lot of implicit bias in our medical model about how we think about care, and we are missing some elements in that model.

HLM: Describe the Camden Coalition.

Brenner: We are a membership nonprofit. With hospitals, patients, primary care, addiction, long-term care, mental health, the whole alphabet soup. We elect our board and officers every year and we make all of our decisions by consensus. We work with the adverse market share that nobody else wants more of.

We had very humble origins about 15 years ago. I was a frontline family doc in the poorest city in the country, practicing in a three-room office treating adults, children and babies.

We had a vision of better care in Camden by reimaging the system. We are a $10 million organization 15 years later. We've created a data-rich and business-oriented approach to delivering care to patients in a vulnerable area.

Camden is a place that is small enough, it's only nine square miles and 79,000 people on mostly publicly funded care, so you can get your hands around the place and move through ideas a little faster than you can in other places.

HLM: Walk us through a typical complex patient encounter.

Brenner: Let's imagine someone who has been to the ER more than 100 times a year, and admitted 11 times. [This is a person] who has four or five very complex chronic health issues, has mental health and addiction issues, and has been in and out of jail from time to time.

We run a regional health information exchange. We would see they've been admitted two or three times over the past six months. We would log into the electronic health records of the local hospitals and pull the records, do a triage.

If it has things like noncompliant, addicted, homeless, those are the people we're looking for. We have staff in all the local hospitals with badges. We go to the bedside with no paperwork and sit down and introduce ourselves and say, 'it seems like you're having a tough time right now. Let's talk about it.' We do care planning.

If they are homeless we move them into a brand new apartment. We have Section 8 vouchers as part of a pilot project. They get moved to the 'burbs. They pick the apartment they like.

We wrap mental health and addiction services around them. They do not have to be sober or in treatment to get an apartment. What we have found is that they need safety first. As soon as they feel safe and have a doorknob and lock, they tend to calm down and are more open to treatment and engagement.

We do a lot of coaching and mentoring. We try not to rescue them. It is critically important not to 'do' for them because you will disable them, and we hope to graduate them.

We can't fix their whole lives. They've had tough lives, but we can nudge them forward in key areas doing root cause and finding the triggers that keep them going back to the hospital.

Perhaps we can displace that need to go to the hospital and point them in another direction.

We've found that the hospital is a teachable moment. You're a little more vulnerable. You're questioning your mortality. You've got time on your hands lying there. You feel disempowered in that hospital gown.

HLM: Have you done a cost analysis?

Brenner: We are an R&D lab. The first iteration of these types of models are going to be more expensive than the end stage.

But, let's do the math. If you're admitted twice in six months, that's $10,000 admission and $20,000 in six months. The Section 8 voucher is $700 a month.

We use community health workers who are about $30,000 a year. We use licensed clinical social workers who are about $50,000 a year. That team can care for about 40 of these folks. You don't have to do incredible math to just break even on this stuff.

HLM: What is the role of the physician in these complex care models?

Brenner: There is absolutely nothing about a doctor's training that make them need to be the head of the care team. In fact, they are poorly trained to lead a team. They have a small piece of technical knowledge.

It would be like taking a structural engineer and putting them in charge of our national transportation system. It makes no sense. I would put a social worker in charge, and that is what I have been doing in my organization, and frankly they are far better calibrated to be leaders than doctors.

HLM: Do you think that could be problematic for doctors?

Brenner: We have some narcissistic clinical bullies who are going to have to learn new ways of ceding space to other professionals. I stand firmly with the nurses and the social workers, and the doctors' professional societies need to cut it out. It's obnoxious.