A middle-aged unemployed woman was repeatedly admitted to a hospital in Camden for serious asthma and severe rashes. Doctors put her on high doses of prednisone but her problems persisted.
, realized that medication alone was not enough to resolve this patient's issues.
After a couple of visits, Brenner -- executive director of the Camden Coalition of Healthcare Providers in New Jersey, an organization that uses community-based teams of multidisciplinary staff to work with the most complex patients -- discovered that the woman had been physically and sexually abused as a child. She is currently homeless and staying with a friend. Nearly every other day, she washes all of her clothes and sheets using twice the regular amount of detergent. She repeatedly cleans the house with bleach and takes several long, hot showers.
"The reason she showers repeatedly is because the time she remembers feeling safe as a kid was when she was living with her grandfather and when she had baths with her siblings," he said.
And her fixation on washing her clothes comes from the detergent's smell, which reminds her of a time when there was less chaos in her life, he said.
The rash was likely caused by a combination of excess detergent and sweat, Brenner determined. The rash followed her underwear line precisely. And the continuous cleaning and bleach exacerbated her asthma, he added.
After gradually reducing her cleaning and showering habits, the woman's asthma and her rash both quieted down, Brenner said. He prescribed her a low dose of selective serotonin reuptake inhibitors for her anxiety and connected her to a health coach who will accompany her to her first psychotherapy visit.
Brenner explained to the woman, "The reason you're having these obsessive thoughts is because you've never ever, ever talked to anyone about all this terrible stuff that's happened to you and it doesn't go away, it's still inside you. And it's going to come out in all kinds of ways."
鶹ý spoke with Brenner, who is known for his work on "" -- using data to identify clear patterns of healthcare overuse and spending -- about reforming a broken health system and the ways social and environmental factors impact health. Brenner's Camden Coalition was granted a 3-year Centers for Medicare & Medicaid Services (CMS) Innovation Award in 2012. This conversation has been edited for length.
How did you start focusing on social determinants of health?
I love taking care of the most complicated patients. I see how expensive all these patients are and how many times they're going back to hospitals. Then I realized we're spending all of our money in all the wrong places, and we don't seem to be making really, really sick people better.
How did you choose Camden ?
I feel like everyone deserves great care and the poor get really crappy care. So, I was going to spend my life in the place that most needed it. Camden's the poorest city in the country. So live there, work there, and make friends there.
In a , Atul Gawande, MD, described how you helped one high utilizer lose 220 lbs, gain control of his diabetes and heart failure, and drastically reduce his hospitalizations. What do you do to give these patients their lives back?
A huge factor for these patients is a very high level of early life trauma -- physical abuse, sexual abuse and maltreatment as kids. And one of the ways they manifest that when they grow up is overuse of the healthcare system. The treatment for that is an authentic healing relationship.
What does that mean?
A lot of patients do things that we don't approve of. We yell at them a lot. An authentic healing relationship is acceptance for who they are regardless of their habits. And when you make the promise you follow through with it. We've found that's the key to this work.
The Camden Coalition doesn't have a physical clinic, is that right?
We don't have a clinic. We're all virtual. We identify people extremely quickly using data-driven tools. We go right to the bedsides. We engage them and we make care plans with them and we navigate them to totally broken systems that don't work. So now the task is how do you actually fix the point of the care delivery.
What do you think of CMS's three-tiered plan to screen patients for behavioral and social issues and to test varying levels of engagement with community resources?
The problem is a lot of the services -- addiction, behavioral health, social services and housing -- are either poorly run, obsolete or inappropriately funded. You're sending people into dead ends. So you'll get a little bit of bump from referrals, but I think there'll be a lot of problems.
As for navigation, you're now going to go with people to make sure they actually get the service. There'll be a bump from that, because if you've got a literate, stable person who can advocate on a patient's behalf, people are more likely to pay attention to you.
The third piece is community level problem-solving, which is actually thinking as a community, "Are the services being structured the way they need to be structured?" There will definitely be a bump from that. I think CMS has really nailed it here.
Earlier you said our systems are broken. Why aren't they working?
I think we've gotten past the point of giving people enough treatment to the point when they're getting too much treatment and the system doesn't know when to stop itself. We have 10,000 baby boomers turning 65 every day. If we deliver care to them like we historically have done the whole system is going to go kaplooie.
What's the greatest challenge to accountable health communities succeeding?
It's the systems. It's not the patients. The patients are the easy part.
If you're the average patient you get average service in the average system. But if you're an outlier in one system the system falls apart. If you're an outlier in two or three systems then it's a complete failure.
If you're a schizophrenic with heart failure, diabetes, and uncontrolled asthma, you're caught between two systems and they may not be communicating with each other.
If you're now an addict with schizophrenia and heart failure, then they're really confused. Systems aren't designed to take care of outliers. We have a one-size fits all delivery model, and that's not very sophisticated.