By Jim Hickman
Over the last decade Dr. Jeffrey Brenner and the Camden Coalition of Healthcare Providers took on a problem that had long plagued the healthcare system: A relatively small number of very sick patients were using the most healthcare resources.
The Coalition sparked the “hot spotting” movement focusing on social determinants of health, or SDOH — the societal and structural factors that influence health — based in part on findings that the ZIP code people live in has more impact on their health than their DNA. Data experts created maps of “hot spots” where the most diabetes or asthma emergencies occurred, which were almost always neighborhoods with high poverty rates.
The Camden Coalition coined the phrase “Better Care at Lower Cost” and devised a program that sought to take better care of low-income people before they incurred enormous emergency room and hospital bills. Their coordinated care approach included home health aides, wellness coaches, and establishing primary care relationships after hospitalization, rather than what Brenner called the existing protocol: “treating the patient like an organ with legs.”
But earlier this month, the results of a randomized controlled trial (RCT) of the Camden Coalition’s signature care management program, the Camden Core Model, were disappointing. Published in the New England Journal of Medicine, the trial showed no difference in readmissions between the intervention and control groups. Some commentators have jumped to criticize the outcome and the study’s singular focus on hospital readmission as the key goal of the intervention. However, most critiques are missing a fundamental point: these results show us that healthcare cannot do this work alone — and just how important it is to build strong communities with the resources that can effectively serve people with complex health and social needs.
Some critiques also gloss over a key point: Social determinants of health matter, but long-term disparities can’t be resolved without addressing the underlying structural problems facing many of our communities. Among other things, this includes identifying critical missing infrastructure (aka “human rights,” as alliances like Housing First might say) such as affordable housing– and demand that government create it. (And while we’re at it, what about dental insurance that actually is insurance rather than a ludicrous pittance?)
As California embarks on a campaign encouraging physicians to screen Medi-Cal enrollees for Adverse Childhood Experiences (ACEs), the Camden Core Model study is a cautionary tale.
Like the Camden Core Model, California’s ACEs screening initiative is led by a physician dedicated to changing social inequities and transforming healthcare. Having multiple ACEs is associated with seven of the major life-threatening diseases in the United States, including cancer and heart disease. Researchers estimate the annual cost of ACEs-related health and social problems to be $748 billion in North America alone, so combating the impact of child trauma is a top priority for California’s Surgeon General, Dr. Nadine Burke Harris.
The parallels between the rise of healthcare “hotspotting” and ACEs screening are striking. Both movements have a similar narrative arc:
· A lone physician in an underserved community — in these cases, Dr. Brenner and Dr. Burke Harris — sees scores of patients with a stark pattern of unmet need by the traditional health delivery system
· A big idea emerges from the physician’s clinical experience that seeks to address structural issues that prevent quality care for an underserved population
· A small group of philanthropists place a “big bet” on a physician/activist to develop a model
· Advocates and critics fail to consider the local and system-wide changes and capacity-building needed before the model can succeed
These observations are not profound, yet they have the benefit of personal experience. I’ve been fortunate enough to work with both Dr. Jeffrey Brenner and Dr. Nadine Burke-Harris, respectively. Brenner and I often discussed the need to break down the silos between health and social services when I directed Sutter Health’s Better Health East Bay initiative (Brenner’s team worked with Better Health East Bay from 2014–2017); I was also on the advisory committee for the Camden Coalition of Healthcare Providers’ National Center for Complex Health and Social Needs. In 2010 I helped design Burke-Harris’s landmark project, the Center for Youth Wellness (CYW), a leading center for ACEs and trauma research, screening, education, and care based in Bayview-Hunters Point in San Francisco. Today I’m the CEO of CYW, which has expanded its model to include capacity-building, community by community. This way we can see which gaps in healthcare and social needs exist, so we ourselves can avoid falling into those same yawning crevices in our safety net.
Recently Brenner explained that he and the Camden Coalition drastically underestimated how few resources there were for their sickest patients, known as “super utilizers.” Talking with The New York Times, he describes a safety net so tattered that patients treated for life-threatening illnesses may be released to a temporary homeless shelter or the streets; it’s not enough to make a difference, he said. In a quote I found heartbreaking, he said, “We’re coordinating to nowhere, essentially.”
The Camden Coalition study raises the stakes for organizations working on ACEs. No brief intervention or short-term infusion of services is a silver bullet that will overcome the long-term harm caused by structural racism, poverty, and multi-generational trauma.
This is the lesson for the ACEs movement. Providers cannot treat trauma properly when people are retraumatized by their living conditions or community surroundings. We need to help remove barriers to care and prevent intergenerational ACEs by addressing social inequities at the systems level — something that is essential to the success of interventions and healing.
We can all learn something from the Camden Core Model study, and in doing so, avoid writing referrals to nowhere.
Jim Hickman, MBA, is CEO of the Center for Youth Wellness in San Francisco’s Bayview-Hunters Point district, which has developed a capacity-building model for communities who are using an equity lens to address ACEs screening and intervention.