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Plotting a path to improve care and increase patient access.

What started in 2002 as a breakfast club made up of primary care providers in Camden, New Jersey has evolved into a larger, more diverse gathering of healthcare providers throughout the city. Eleven years later, the Camden Coalition of Healthcare Providers is an independent, non-profit organization striving to improve the health status of all Camden residents by increasing capacity, quality and access to care.

Jeffery Brenner, MD

Founder and Executive Director

Camden Coalition of Healthcare Providers

Jeffrey Brenner is the Founder and Executive Director of the Coalition. He is a family physician and practiced in Camden for eleven years as a front-line primary care provider for patients of all ages. Having owned a private practice in Camden, he has experience in implementing electronic health records and running a paperless office, open-access scheduling, as well as first-hand knowledge of the various challenges facing primary care in the current health system.

He currently serves full-time as the Coalition's Executive Director, where he spends much of his time meeting with stakeholders and policymakers, advocating for the models of care the Coalition has developed and demonstrated through data centric results. Jeff is a faculty member of the Robert Wood Johnson Medical School in Camden and is also a former resident of Camden, having lived in the city for over eight years.

He is a graduate of Vassar College and the Robert Wood Johnson Medical School.

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What is the Camden Coalition's approach to population health management?


There is a real conundrum in population health - do you work with patients on the way up, predicting upcoming expenses? Or do you work with patients who are already expensive? Thus far, the predominant model of care management has been to focus on the predicted model where they are seeing more dramatic results by working with the most expensive. Our belief is to start at the top with the most extreme patients and work your way down. You learn a lot this way.


What has helped drive Camden Coalition's success?


The city is only nine square miles, with 79,000 people, three emergency rooms, two in-patient hospitals and 15 primary care offices. It's pretty contained. There is one major homeless shelter, two behavioral health entities - so this is a good real-world lab for figuring out what innovations it will take to deliver better care at lower costs.

Because the city is the poorest and most dangerous in the country, it is mostly publicly-funded healthcare through Medicaid and Medicare. It's a phenomenally good place to figure out the laws of physics that drive hospital utilization and what we do to intervene to reduce unnecessary utilization, improve quality and reduce costs. The lessons we learn here can be utilized elsewhere. They want to 'scale' this program.


What is your approach and why have you been so successful getting the opportunity to work with the major hospitals and medical groups in Camden?


There are a couple of key pieces - developing relationships and forming partnerships. I've been a provider in the community for 15 years, so I understand that this takes relationship building. We've spent a lot of time building relationships throughout hospitals with a lot of different decision-makers. These institutions are also mostly suburban-facing. They don't necessarily want to fill their hospitals with underserved Camden residents. It's an adverse market share so it's a win-win for us to work together to help reduce utilization by Medicaid recipients.


Which of your core programs are the most impactful?


Two programs are crucial - the Health Information Exchange and the Primary Care office redesign.

The Health Information Exchange is powered through both static and real-time clinical data. It's used as a driver for interventions - so we know who has been admitted and why. After this information is established, we have outreach teams who meet with patients in hospitals, visit them at their house within 24 hours of discharge and take them to their primary/specialty care office. The whole workflow is crucial because the first 30-90 days after a hospitalization is critical.

Our Primary Care office redesign is a difficult challenge because primary care is undercapitalized, understaffed and underperforming. It's not accomplishing the things that the Camden Coalition aspires to accomplish. So, we're deep inside the offices - thinking about workflow, staffing models and leadership models to catch every hospitalized patient.


How do you work with social workers?


For us, it's about accompaniment, warm hand-offs and building relationships with patients. But we also project manage to ensure it's organized. In order to scale this kind of work you need to have great staff out every day reporting data about what they do while building these relationships with patients. And they need to be able to do this efficiently. There's being effective and being efficient. It's hard to do both at the same time - but that's the goal.


What do you see as the role for the Camden Coalition?


We think the field of population health is 30 years behind where it needs to be; we can separate Siamese twins, transplant hearts and lungs - but we don't understand all the drivers of healthcare utilization. We don't know how to intervene, improve quality, reduce costs. How do you hire the right people and train them the right way, track what they are doing, redefine primary care, sync them with specialty care - there is so much to figure out and we are at the very beginning.

There's a lot of work to do. Camden is an innovation laboratory, but we can't do it alone. All over the country there are people working on the same problem, so it's important to share information and ideas. And people are starting to listen - particularly with certain figures like one percent of patients making up 30 percent of the costs.