Forefront Excerpt: Urgent Care

Credit: Greg Pizzoli

For years, Trenton medical centers provided shoddy service, with patients sometimes enduring wait times exceeding 70 days. And yet, thanks to the efforts of a handful of doctors and organizations, the New Jersey capital has become one of the first U.S. cities to try out a patient-centered form of health care known as “hot spotting.”

In Forefront this week, Jake Blumgart looks into this emerging practice, examining the dire circumstances by which it came about and its chances for success in New Jersey and beyond.

When Gregory Williams is out on the Trenton streets, he talks with a group of young men, mostly in their 20s and 30s, who are staying at a shelter but badly want housing of their own (particularly galling is the shelter’s rule that those who want to stay the night must show up by 4pm in warmer parts of the year, which makes getting work awfully tough). Williams tells them he’ll be back soon to discuss options.

“That is a big part of what we do with the Trenton Health Team,” said Brownlee. “We [meet with] individuals who are homeless and find the right types of support services for them and get them into housing. There is a synergy that allows us all to take bigger steps as a group than if we were doing it by ourselves.”

Another revolutionary aspect of THT’s work is the forthcoming Health Information Exchange, a universally accessible database of patient records. (It is not mandatory and patients can choose to opt out.) The database will allow providers across the city to see a patient’s medical history: Tests received, medicines prescribed, lab results. This will prevent expensive and unhelpful duplication of services and eliminate the patient’s burden of recalling complex pharmaceutical names or the exact exams they’ve received. A doctor or ER nurse will be able to access their detailed medical history with a few keystrokes. The system is projected to be operational by the end of 2012.

The patient-oriented, collaborative care being spearheaded by organizations like THT, the Camden Coalition and similar projects across the country is very similar to the practices of the universal health care systems of other industrialized democracies. France, for example, provides its citizens with a health care card, eliminating expensive paperwork and, like Trenton’s forthcoming Health Information Exchange, allowing providers to immediately access an individual’s detailed medical history. Britain’s National Health Service rewards doctors based on outcomes, akin to the ACO model that Trenton and Camden hope to utilize, which would allow health care providers to keep a portion of the money they save by keeping their patients healthier and out of the hospital. NHS also operates a free 24-hour phone service — a nationwide version of giving Nucero’s number to Kingsbury residents — that patients can call any time of the day or night to receive a consultation, which is cheaper than a doctor visit.

Brenner and the Camden Coalition have a Health Information Exchange up and running, but they very purposefully drew a line around the city of Camden. Expanding it to the whole region would have meant getting embroiled in the greater political complexity found across the Delaware River in Philadelphia. There the economy very much relies on the "eds and meds" model of economic development, where hospitals and research complexes create the large-scale, relatively stable employment that manufacturing used to provide. With its nimble infrastructure and bias against hospital stays, hot spotting could be seen as a tacit threat to these institutions.

“Philadelphia’s entire economic model is built on cutting, scanning, zapping and hospitalizing Philadelphia residents,” Brenner said. “Much of the city’s economic renaissance has been based on an expansion of the medical industrial complex, the expansion of hospitals. I don’t know how much traction the idea of better care at lower costs with fewer hospitalizations is going to get.”

This isn’t unique to Philly. Most American cities that lost their manufacturing bases long ago depend on hospitals and universities to anchor their economies. These hospitals operate along the same lines as a hotel or an airline: Fill the beds. Every time a patient checks in, that’s another pot of cash, no matter if they were just in the hospital the other week and the care failed so badly that they had to, well, be hospitalized again. It’s called Roemer’s Law: “A hospital bed built is a hospital bed filled.” Sure enough, close to 20 percent of American seniors are back in the hospital within 30 days of being released. Not all of these readmissions are avoidable, but many are. Brenner estimated that if the rewards were switched and preventive, patient-based care became the norm, the country would need a third fewer hospitals.

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Tags: forefront, newark, camden, healthcare, trenton, hot spotting, health information exchange, roemer's law