By Susan Milstrey Wells
Jeffrey Brenner, MD, was catapulted into the national spotlight six years ago when a New Yorker article described his efforts at “hot spotting”—using data to identify health care’s “high utilizers” in Camden, N.J.
Brenner, a primary care physician, used this information to provide wraparound medical and social services to these patients through the Camden Coalition of Healthcare Providers, which he founded. His model has been replicated across the country, including in Aurora, Colo. Now Brenner is taking his model nationwide.
On Jan. 31, 2017, Brenner announced that UnitedHealthcare, one of the nation’s largest health insurers, will invest $15 million in the Camden Coalition over three years to support some of its pilot projects, including its Housing First program. Brenner will concurrently leave the Coalition he founded to become senior vice president of integrated health and human services at UnitedHealthcare and head its myConnections program, which is intended to help connect low-income patients with social and government services.
With this move, Brenner has said he hopes to assure that the model he developed in Camden is accessible to millions across the country. As he prepared to leave the Coalition, Brenner reflected on what he has learned about providing care to vulnerable populations. Highlights of our conversation follow.
What is the most important thing you’ve learned in doing this work?
The biggest thing we’ve learned is how much we have to learn. In order for us to really get our hands around this and build a reliable field, we need high-quality, multidisciplinary research and a clear bio-psychosocial framework, and we don’t have that right now. We didn’t make progress in the war on cancer until we did the human genome project and then learned the alphabet. I think we’re at 1972 in understanding how people use the health care system.
Where do we start?
By understanding that poverty is at the center of this work. We now understand the biology and physiology of income inequality and poverty and how it effects people. It creates a sense of helplessness and toxic stress. Being poor in Camden is like the feeling you get when you’ve had the worst thing ever happen in your life and you can’t sleep, you’re tossing and turning, and you’re stuck like that.
You’ve written about the role of trauma in your patients’ lives. What is the relationship between poverty and trauma?
Growing up poor increases the chances that you will be exposed to the types of traumatic events that lead to toxic stress. Your family, your neighbors and your whole community are under stress, so you are going to be less resilient. I believe that trauma-informed care may be the most powerful technology that we’ve come up with in the last 100 years.
What role do physicians play in addressing toxic stress and its impact?
We must recognize that medicine, as we currently practice it, is a very weak tool to solve a really big, complicated problem. [Currently,] we take people who are stressed, anxious and overwhelmed, and then we test them, medicate them and recreate their trauma. We must practice team-based work and recognize the importance of data in designing and furthering these partnerships.
How do social determinants other than poverty impact the health of the people you serve?
“Determinants” is the wrong word. These are social “correlates.” Determinants means that things are absolutely connected and irrefutable. But we know that not every homeless person is unhealthy and not every unhealthy person is homeless. Social determinants imply hopelessness. Viewing such factors as poverty and trauma as social correlates means I can reduce risk factors and increase protective factors.
Give me an example of how health care providers can address social correlates.
Let's think of homelessness, not as a random character flaw, but as a disease that has an origin and results in a certain set of predictable behaviors. We know that the vast majority of chronically homeless patients have severe early-life trauma that leads to difficulty forming relationships. They use substances to cope and may have a mental illness.
Now, it makes sense that being in a shelter with 70 other people is terrifying to them. So, the behavior of sleeping on the streets goes from being a mystery to having causal pathways we can treat and potentially cure. Permanent supportive housing, exemplified by Housing First models, becomes an appropriate treatment.
How does this understanding impact your work?
The most important work I’ve done in my entire career, and we’ve done as an organization, has been in the last year. We got 50 Section 8 housing vouchers from the State of New Jersey and then raised money for services. We’ve been putting people who have extreme medical complexities, including mental health and addiction problems and social barriers, into brand-new apartments and wrapping services around them.
Randomized controlled trials of permanent supportive housing gave us some indication that our results might be promising. But we’re seeing the most phenomenal outcomes I’ve ever seen in our work. Preliminary analysis shows a 39 percent reduction in hospital encounters, as measured by combined emergency department and inpatient encounters per day, compared to the 2 years prior to enrollment. We are in the midst of a longer-term, mixed-methods evaluation of the program and anticipate seeing cost reductions, as well.
What surprises you most about this work?
How hard it really is. This is about the workforce and the way that we train doctors, nurses and social workers. It’s about payment. It’s about the way we use data. It’s about the way we structure clinical models, and it’s all become obsolete. This is not about breaking down silos; this is about completely rethinking some basic assumptions about the culture of care in our country.
How do others replicate the Camden model?
You hire the warmest, kindest people you’ve ever met, train them in behavioral health and addiction, and get really good managers who can take care of themselves and do reflective supervision. You get data so you can measure what everyone is doing every day. Then you set up an infrastructure to identify the right patients, target them and show up at their bedside the day they’re admitted to the hospital.
How will potential changes in the Affordable Care Act impact your work?
The folks we’re working with are so poor and underserved, it’s unlikely they’ll lose Medicaid. Better care at lower cost for complex patients is a bipartisan issue, so the core of our work will continue.
Edited and condensed for clarity and brevity.