Hot Spots and the Camden Coalition

As health care evolves, those of us dedicated to caring for people in our community are constantly challenged with how to prevent illness, as well as how best to treat patients once they become ill. We know if we can address the underlying causes of illnesses, we should be able to help our patients—and our whole community—stay healthier. We also know that if we can improve the health of individuals who utilize the lion’s share of local resources (e.g., health, social services, law enforcement, and education), we’ll be helping them as well as the community at large.

In 2011, Dr. Atul Gawande (neurosurgeon and best-selling author) published an article for The New Yorker magazine touting the work of Dr. Jeff Brenner and his organization, the Camden Group. Dr. Brenner did pioneering work using emergency room data to identify “hot spots”—places where certain people spent far more time in the hospital than most. By hot spotting, Dr. Brenner identified patients whose healthcare needs were not getting met; he then reshaped the way health care was delivered so those same people could get the help they needed, and he reduced the overall cost of their care in the process.

About that same time in Mendocino County, a group called the Mustard Seed Coalition undertook a grant-funded pilot project with a similar focus called the Chronic User System of Care (CUSOC), using intensive case management and open communication among local agencies to help those who signed up for the project.

The goals were:

1. To improve the health care of these individuals by moving from a crisis-based approach to a preventive and management approach, and
2. To reduce the overall community costs of health care and social services.

The coalition included Ukiah Valley Medical Center (UVMC), MCHC Health Centers, the Mendocino County Jail, the Ford Street Project, Mendocino County AIDS/Viral Hepatitis Network (MCAVHN), and others. Like Dr. Brenner, members of the Mustard Seed Coalition found that by shifting from episodic care to an approach with far more support (such as reminder calls, check-ins, same-day appointments), high intensity patients were able to stay healthier and spend less time in the emergency department or intersecting with law enforcement.

When the Affordable Care Act passed and grant funding for the CUSOC project ended, high utilizers eventually began receiving care through Partnership HealthPlan of California’s Intensive Outpatient Care Management Program (IOPCM).

While IOPCM is an excellent program, it is only part of the overall approach to creating a healthier community. UVMC has been working with North Coast Opportunities and many folks from the original Mustard Seed Coalition, under the banner of Healthy Mendocino, to determine and address the most pressing health needs in Mendocino County:

1. Poverty
2. Housing
3. Mental Health
4. Childhood Obesity and Family Wellness
5. Childhood Trauma

By working together to address these issues, we have created, as Susan Baird Kanaan so aptly phrases it, a “community of solution”.

To continue to address population healthcare issues and to identify those individuals who need more support (to do hot-spotting of our own), Adventist Health has decided to work with the Camden Coalition, which was founded by medical hotspotting pioneer Jeff Brenner.  Representatives of Camden visited Ukiah during the first week of October, and met with local organizations dedicated to helping people in our community improve their physical and behavioral health (i.e., Manzanita Services, County Health & Human Services, Ford Street Project, MCAVHN, Plowshares, Healthy Mendocino, Medstar Ambulance, Ukiah United Methodist Church, Kol Ha’emek Jewish Community, NorCal Christian Ministries, Redwood Quality Management Services, and others).

Camden representatives also visited the UVMC Street Medicine program at Plowshares, as well as a program at our sister hospital, St. Helena Clearlake, called Live Well—a program we plan to bring to Ukiah. The people from Camden are interested in sharing best practices and learning how we’re approaching the challenges of providing health care in a rural, socio-economically depressed area.  We’re excited to work with them to learn more about how their successes can be translated here.

 ###

Gwen Matthews is the President and CEO of Ukiah Valley Medical Center, a part of the Adventist Health network.