"When I came into this program it was like, really, really, how can I say this, at a time I needed support. My closest family member is 1,500 miles away. I was going through something, and the next thing I know, these wonderful people show up on my doorstep, and it was like they were basically more than just a support group for me to gain and get my health together. They have been there for me, when I say, they have shared good positive tears, tears of joy…they have been there for me. I really appreciate it… This is what the outcome has been for me so far, and I know it’s going to get a lot better." says Trondail.
It was a hot and humid day in Houston — the oppressive sort that makes one contemplate retreating to air conditioning immediately after stepping outside. Our patients did not have that luxury.
Breaking Boundaries - Health systems are evolving and advancing their strategies to address social determinants of health
Published On: February 2017 in Deloitte Center for Health Solutions. Read the story here.
More than a decade ago, family physician Jeffrey Brenner, inspired by police department strategies to map crime data to identify "hot spots," began to use ambulance records and emergency department (ED) data to predict and aim to address health care hot spots.
Published On: January 2017 in Kaiser Health News. Read the story here. This KHN story also ran on PBS NewsHour.
HOUSTON — Donning a protective gown, rubber gloves and a face mask, Dayna Gurley looks like she's heading into surgery. But Gurley is a medical social worker charged with figuring out why her client, a man who uses more health care services than almost anyone else in Houston, has been in three different hospitals in the last month.
The patient, who asked not to be identified, has chronic massive ulcers, AIDS and auditory hallucinations. He rents a cot in another person's home but is more often homeless, with no family to help him.
"A way to save money when half of all health costs is spent on a fraction of patients" - PBS NewsHour
Published On: January 2017 in PBS NewsHour. Read the story here.
Health care "super-utilizers" make up just 5 percent of the U.S. population but they account for 50 percent of health care spending. As health care costs continue to rise, providers are trying to figure out how to find these patients and get to the root of their problems. But the looming repeal of the Affordable Care Act may disrupt those efforts.
Published On: December 2016 in Episcopal Health Foundation. Read the story here.
He was sitting in his old wheelchair with his phone in his hand. He was grey, had difficulty breathing and was very confused. We immediately called 911.
Timmy was on the outside of the health system looking in. And it almost cost him his life.
The Camden Coalition of Healthcare Providers, led by MacArthur Fellow and primary-care physician Jeffrey Brenner, has won renown for its efforts to address the complex needs of Camden's sickest residents.
Now, on the heels of establishing the National Center for Complex Health & Social Needs this year, the Camden Coalition has won a grant of up to $1.65 million over three years from Aetna Foundation to develop a curriculum that will help other cities adopt the data-driven approach Brenner has used in Camden.
Houston-area emergency rooms are packed and the taxpayer price tag is climbing. But one doctor's idea could not only shorten ER waits and save money, but could dramatically improve the health of Houston's most vulnerable patients...
Read the complete article on the ClickToHouston here.
Published On: Jun 17 2014 in KPRC.
Houston health innovation center reduces ER trips
A new program of identifying patients who most frequently go to Houston-area emergency rooms and then coordinating their medical care has reduced ER visits by 85% in just three months, according to preliminary findings released today by the Primary Care Innovation Center (PCIC).
PCIC research is based on patients identified as "superutilizers" – patients who use emergency rooms across Houston more than 10 times in one year. During the three months before the PCIC program, eight of those patients visited an ER a total of 65 times.
High utilization by intensive users
Intensive users of medical services account for 21% of the Medicaid budget in Texas. Four patients used emergency rooms at 19 different Houston hospitals a total of 179 times last year, according to Primary Care Innovation Center, a Houston nonprofit. One patient had a total of 56 visits to 10 different emergency rooms. These intensive users of medical services - in the jargon, "super-utilizers" - account for 21 percent of the Medicaid budget in Texas, according to Primary Care Innovation Center.