By Katie Kerwin McCrimmon
AURORA The Colorado community devastated by a mass killing will now become one of only four sites selected for the most promising revolution in health care: hotspotting.
The movement began with a different senseless shooting in 2001 in Camden, N.J., a city that tops the country for both crime and poverty.
Its a place filled with urban ruins, where a tree is shooting up through a once-stately Carnegie library, where budget cuts recently forced the layoffs of half the police department and where gunshots frequently pierce the night sky.
We also end up with all the people no one else wants: the mentally ill, sex offenders, those recently released from prison, said Dr. Jeffrey Brenner, a family doctor, who lives and works in Camden and has become the accidental revolutionary who is turning the U.S. health system upside down.
Brenner came to Colorado this week to attend the Colorado Health Symposium in Keystone sponsored by the Colorado Health Foundation.
Started with a shooting
On a February night in 2001, a 22-year-old black man was shot while driving through a neighborhood on the edge of Rutgers University. Brenner lived a couple of doors away and a neighbor called him to help.
He raced out with his stethoscope and was horrified to find the police doing nothing as the young man lay dying in a pool of blood. He had been a Camden success story, a young man poised to graduate from Rutgers with hopes of someday becoming mayor of his hometown. Brenner screamed at the cops: Why didnt you guys do anything? They claimed they didnt want to dislodge the bullet.
To me, it showed an unbelievable disregard for human life, Brenner said.
Brenners basic impulse to care for fellow human beings is at the core of his work and the new experiment in Aurora, which will be overseen by health experts at Rutgers and the organization Brenner founded: the Camden Coalition of Healthcare Providers.
From St. Thereses Catholic Church in north Aurora, just a mile from where accused Aurora shooter James Holmes lived, Aurora Health Access, a faith-based group of parishioners, community organizers and immigrants from Mexico, is trying to give people in their community what they do not have now: a true, functioning health system.
We are called upon as people of faith to care, to relieve the pain of the sick, said Rich McLean, a retired military systems analyst, who lives near St. Thereses and is joining with his neighbors and the interfaith activist group, Together Colorado (formerly Metro Organizations for People), along with its health partner, the Metro Community Provider Network.
The Aurora experiment aims to save millions in hospital costs while also giving people better care. Volunteers, health workers and church activists will put into practice the hotspotting concept that Brenner pioneered.
Inspired after witnessing the young Rutgers students death, he started mapping crime and health data and found that a handful of people were costing the system the most money.
In Camden, Brenner found that 1 percent of the people were racking up 30 percent of health costs, amounting to millions of dollars a year. He has found that same statistic to be true in other communities, and it may very well turn out that a tiny percentage of Auroras sickest patients also cost the health system here the vast majority of the expenses.
A preliminary survey by the Aurora Health Access coalition found that from July 2010 to June 2011, residents in two target Zip Codes, 80010 and 80011, visited emergency rooms 30,694 times at nearby University of Colorado Hospital and Childrens Hospital Colorado. Frequent ER users who lived in the two Zip Codes those who visited an ER five or more times in a year accounted for 43 percent of all the visits among the frequent ER users in Aurora. In the 80010 Zip Code, about one-third of people live at or below the federal poverty rate.
The three-year experiment in Aurora is just beginning and www.HealthPolicySolutions.org will track the groups progress. The federal Centers for Medicare and Medicaid Innovation awarded Rutgers a $14.3 million grant in June to pilot the Camden model in four communities: Aurora; San Diego; Allentown, Pa.; and Kansas City, Mo. The goal is to find the costliest patients; save $70 million on their care in the four communities; and reinvest the savings to provide better health care.
Many of Camdens high utilizers lived in two of the citys buildings, a nursing home and a high-rise with subsidized apartments for seniors. Many qualified for both Medicaid (the health insurance program for the poor) and Medicare (the program for seniors).
Brenner started finding the patients with the most frequent ER visits and hospital stays and did the unthinkable. He gave them more care, not less. A team of nurses and health coaches made house calls, accompanied the patients to doctor visits, streamlined their medication and helped them get well so they could stay out of hospitals.
The health team finds unconventional cures, such as helping a man with severe asthma get his mold-infested home repaired so it would stop triggering his debilitating asthma attacks.
Our story is not a story of poverty. Its a story of broken health care and disorganized care, Brenner said during his visit to Keystone.
Brenners idea of saving millions from the health system is controversial because he aims to give people more care from nurses and inexpensive health coaches.
Lost hospital profits
Cutting health costs will mean lower profits for specialists and hospitals.
Hospitals are like hotels or airlines. Is the place full? Are there well-paying patients in the inn?
Theres a lot of money to be made from a sickness system, Brenner said. Its going to be a very wrenching change to think about how we transition all of this to a different system.
He compares the change to the de-institutionalization of psychiatric care. It has taken 30 years to try to build a new community-based structure to replace the expensive old psychiatric hospital model. And mental health systems remain fractured from medical systems.
The fundamental problem with health care now, Brenner says, is that the fee-for-service model, where doctors get paid for procedures, rewards expensive tests, hospital stays and specialist visits while failing to keep people well. Before he had to shutter his own family practice in Camden, he said he made more money running from room to room to room treating colds than he did sitting down and spending time with the patients who needed him the most those with complex and difficult health problems.
That patient slows you down, Brenner said. We set a really high price if you cut, scan, zap or hospitalize someone.
But primary care providers get reimbursed as little as $19 for a patient visit. Both doctors and patients feel that the system is cheating them, Brenner said.
So much desperation
North Aurora does not have high-rise buildings full of the poor. Instead, struggling people live in squat one-, two- and three-story brick apartments just off of Colfax Avenue or they are homeless and congregate near the citys parks.
Many are new immigrants from Mexico. Many are older, but dont yet qualify for Medicare, like a man in his late 50s who lost his long-held job at a restaurant when joint problems made it hard for him to be on his feet all day. Now hes unemployed, sleeping in his daughters living room and cant afford to get care for his painful joints. Another resident was having a heart attack, but stayed home out of fear that without a Medicare supplement, care would be impossible to afford.
A lot of folks in our community have never been to a doctor. The care we have here is in the ER, McLean said. Denver has a health system and we dont. Aurora is as big as New Orleans and Syracuse and Pittsburgh.
Hotspotting in Aurora
- Target Zip Codes: 80010 and 80011
- Survey from 2010-11 found 30,694 ER visits from those Zip Codes to CU Hospital and Childrens Hospital
- High utilizers visited at least 5 times
- High utilizers from those two Zip Codes comprised 43 percent of all frequent ER visitors in Aurora
- $14.7 million, 3-year-grant begins now in Aurora; San Diego; Allentown, Pa.; and Kansas City, Mo.
- Goal: save $70 million and reinvest it in better health
- Modeled on original hotspotting work in Camden, N.J.
- Pioneer: Dr. Jeffrey Brenner, family physician and founder of the Camden Coalition of Healthcare Providers
- Colorado partners: Together Colorado, Metro Community Provider Network, Aurora Health Access, faith-based volunteers from St. Thereses Catholic Church
When the poor and uninsured in Aurora are sick and cant get an appointment at clinics with long waiting lists, they go instead to ERs where they get minimal care, then can be hounded by debt collectors, McLean and his fellow activists say.
Eliana Mastrangelo is the lead health care community organizer for Together Colorado. She and volunteers walked door to door in two of Auroras poorest Zip Codes to survey residents about their health needs.
We met one gentleman, an undocumented Latino with no health insurance in his late 40s, Mastrangelo said.
He hurt his hand so he went to the ER. He was charged $1,400. He had no X-ray. They gave him pain meds and sent him home.
The workers felt the man got poor care at an exorbitant cost, a double whammy. The man is paying his bill, little by little, month by month.
Volunteers who surveyed the Aurora residents said they consistently heard that people want a family doctor whom they know and trust. They want to pay a fair price to see a provider, but dont know where to find that care or how to access a confusing system. All they know is that the ER is open 24/7 and with few other options, if people are in pain, they will go to the ER and wait hours to be seen.
McLean said he knew he had to make it his mission to help people in his community with health care when he got a call while driving on a road trip through New Mexico in 2007.
St. Thereses had started up a health care campaign, McLean said.
A 15-year-old girl was on the phone. The parish priest had given her his phone number.
I dont know who to turn to, the girl said. She told him she been diagnosed with ovarian cancer. Her parents spoke no English and she had no health insurance.
What help can you give me or I am supposed to go and die, the girl said.
It just blew me away, this very personal thing and she had to call a stranger, McLean said.
He was able to get the girl care through Childrens Hospital and she is doing well. But McLean found a new calling.
The need is so great. There is so much desperation, he said.
Graciela Moreno is a nurse and parishioner at St. Thereses. Shes one of the leaders of the Aurora movement.
Originally from Mexico, Moreno settled in Aurora because her brothers and sisters moved there. They found it affordable and homey. Moreno says fellow immigrants are utterly shocked that there is no basic health system in the U.S.
She has a 16-year-old son with asthma. Because of her medical background, she is able to help him keep his asthma under control, but she has had friends who have had to go to the ER for ailments like urinary tract and ear infections.
Ive struggled a lot to get medical services. If everyone struggles that much, its got to be difficult, Moreno said.
Fear of deportation also keeps some immigrants from even trying to access the health systems, Moreno and the other volunteers said.
Faith-based advocates mobilized
The four new hotspotting initiatives are all taking place in communities with strong faith-based community groups like Together Colorado that are members of the PICO (People Improving Communities through Organizing) National Network.
Its no accident that faith and community organizing are at the core of this health revolution.
We believe that in order for there to be true health reform, the people who are going to be most reliant on it are the ones who should shape it, said Kamara OConnor, lead organizer for PICOs Bring Health Reform Home project.
What were trying to do is shift our country toward more primary and preventive care, said OConnor who also spoke at the Colorado Health Symposium.
While the movement is revolutionary, OConnor said its also a back-to-basics concept where people get high-touch simple care from people they know and trust.
A hundred years ago, the doctor would always visit a patient at home, OConnor said. What were really aiming for is a cultural shift. Were trying to get away from a bureaucratic system about paperwork where people are anonymous to a system that really values people and builds relationships.
Brenner says hotspotting alone cant fix health care. But, it provides a glimmer of hope that we can fix a broken system that otherwise will bankrupt us.
Its hard to be caught in a system thats not working. Its frustrating for the doctors and frustrating for the patients, Brenner said.
Hotspottingis a strategy so you can target different areas of need, Brenner said. When you build a great program to deal with very frail elderly patients, thats hotspotting. When you build a great program to take care of babies who are coming out of the NICU (the neonatal intensive care unit) and whose moms and families are overwhelmed, and you want to keep that baby from getting rehospitalized, thats hotspotting. Hotspotting is making sure the people who are in need get their needs met.