Late last year, help came from a nurse with the nonprofit Camden Coalition of Healthcare Providers, who visited Freeman at her home in the city's Centerville section.
The nurse watched as Freeman checked her blood sugar levels. She provided a pillbox to organize her medications. She put Freeman on a meal schedule and advised her to substitute tuna and grilled chicken for pasta and hot dogs. And she connected her to a diabetes specialist.
"It's under control now," Freeman said of her diabetes. "I don't have problems with it."
Controlling diabetes and reducing costly hospital stays are two goals of Jeffrey Brenner, the coalition's executive director and a physician with Cooper University Hospital. Backed by several large grants, including a recent $2.8 million federal Health Care Innovation Award, Brenner and his team are undertaking one of the nation's most important health-care experiments. They aim to halt the inexorable rise in health costs in part by caring for patients more effectively in one of the country's poorest cities.
Much of their focus is on diabetes. "If you improve the care for diabetics," Brenner said, "you improve the care for lots of complex patients."
A $5 million patient
The coalition started by looking deeply at the city's dysfunctional health system.
Hospital bills showed that half of city residents use the ER each year, often for minor problems. Just 13 percent of patients were causing 80 percent of the costs. And residents of two apartment buildings, Northgate II and Abigail House, were costing the most, racking up $83 million and $92 million in charges from 2002 to mid-2008.
One Camden patient alone rang up nearly $5 million in charges over five years.
The coalition has responded by organizing teams to reach out to the sickest patients and put a nurse-led clinic in Northgate II. It helps primary-care practices get electronic medical records and offer patients more same-day appointments so they can avoid the ER. And it even works to reduce shootings by meeting with people involved in those incidents and helping them escape the cycle of violence.
State legislation enacted last summer will help Brenner take his ambitious approach to the next level — creating a Medicaid accountable care organization (ACO) in Camden. The effort could enable providers to keep some savings if they meet quality benchmarks for patients.
"An ACO, in my mind, is made up of lots of well-run projects that add up to better care at lower cost," Brenner said. "We've been putting the training wheels on and learning how to build the components."
Focus on diabetes
Diabetics will continue to be a focus of the group's effort. In Camden, 29 percent of inpatient hospital costs went to treat diabetics in 2009, according to the nonprofit data warehouse CamConnect, where Brenner is a board member. Nationwide, medical expenses for diabetics are more than double for people without the disease.
The most common form of diabetes, type 2, occurs when the pancreas does not make enough insulin to regulate blood sugar normally. Symptoms include high blood-sugar levels, increased appetite and thirst, fatigue, and blurred vision. There is no cure.
Treatment typically requires a regimen of healthy eating, regular exercise, and oral medication or insulin injections. "There is no simple, straightforward solution for the vast majority of people," said Arthur Chernoff, chair of the Division of Endocrinology at Albert Einstein Healthcare Network in Philadelphia.
When diabetics don't manage their disease, the complications can be staggering. Diabetes is the leading cause of kidney failure, nontraumatic lower-limb amputations, and new cases of blindness. It's a major cause of heart disease and stroke, and the seventh leading cause of death in the United States, according to the Centers for Disease Control and Prevention.
Camden's diabetes rate is higher than the national average. CamConnect says nearly 13 percent of the city's adults are diabetic, compared with a national rate of 11.3 percent.
That's partly because of Camden's demographics. Poor people in dangerous communities tend to be at higher risk for obesity because they lack access to healthy foods and safe places to exercise. Also, the CDC says, diabetes risk is 77 percent higher for blacks and 66 percent higher for Latinos than for whites. Camden is about 48 percent black and 47 percent Hispanic.
Innovations in care
Innovative approaches to diabetes control will become even more important if federal health-care reform progresses to cover more people and stretches the already short supply of primary-care doctors.
The Camden coalition augments doctor visits with a care management team that makes home visits and gives nutrition education classes. "You need a multipronged effort to change the management of chronic illnesses in Camden," said Steven Kaufman, the coalition's staff endocrinologist and a diabetes specialist at Cooper.
One thing that makes the coalition's approach exemplary is its focus on "trying to get a critical mass of effort" to help underserved diabetics, said Ann Albright, director of the CDC's Division of Diabetes Translation.
Since the coalition landed a $2 million, five-year grant from the Merck Foundation in 2009, it has been transforming 10 city primary-care practices to patient-centered medical homes. These practices offer a team-based approach that can tap nurse care coordinators, social workers, and behavioral health caregivers. A $3 million grant last year from the Bristol-Myers Squibb Foundation will accelerate practice changes at Virtua's Kyle W. Will Family Health Center and River Road Primary Care.
Six city practices have put in electronic health record systems, some funded by the coalition. Patrick Ervilus, a nurse practitioner in Cramer Hill, said the coalition gave his practice such a system, along with training.
"We're able to be more effective in tracking down [patients] who are in need the most," he said.
How to avoid complications
While access to primary care is key to diabetes control, patients largely face the disease on their own. To educate Camden's diabetics, the coalition helped launch three classes in the city, including one in Spanish.
At a typical class at the Fairview Village Community Center last year, the topic was blood glucose monitoring. Francine Grabowski, a registered dietitian and certified diabetes educator, led the class, outlining the dangers of blood sugar surges, which had plagued two of the class participants in the previous week. Grabowski showed the class foods they could eat, such as fruit snacks, if their blood sugar dropped.
When talk shifted to meat and protein, Grabowski urged participants to make sure the protein per serving of meat was at least double the fat per serving. She passed around food packages and asked class participants to read the nutritional information.
Carmen Camacho, an animated 64-year-old diabetic, discovered a package of breakfast sausage with twice as much fat as protein. "You're not buying meat," Grabowski pointed out. "You're buying fat."
Noting that she'd seen the sausage sold for just 88 cents, Camacho said, "People have to live on an income."
Diabetes education encourages patients to be more self-reliant, said Chernoff, the Einstein endocrinologist, who is not affiliated with the Camden effort. "If the patient is empowered to take care of themselves and learns how to do it, that's a huge step in solving and dealing with and avoiding a lot of the complications that can emerge."
The coalition's care management team, which helped Freeman, steps in when Camden diabetics need more support than weekly classes can provide.
The team initially focused on the highest users of ER care, but now targets high-cost hospital patients identified by UnitedHealthcare's Medicaid unit in Camden.
Peering into a patient's refrigerator and medicine cabinet gives providers "invaluable pieces of information," Chernoff said. "There are some people with whom it might make the difference [between] having 15 or 20 trips to the hospital versus none."
Equally important is access to a case manager during off hours, when the only other option for care might be the ER, Chernoff said.
So far, indications of success for the Camden diabetes initiative are anecdotal. Brenner said a thorough study will take six to nine months to complete.
Administrators from Camden's three hospitals — Lourdes, Virtua, and Cooper — said the coalition had improved primary care and cut unneeded admissions and costs.
"The coalition gives us hope that we can really make a difference for the population," said Joan M. Gray, director of ambulatory services at Virtua Camden. "Whereas everyone was struggling individually before, working as a group truly feels different. We have a vision of what it can be."
Christina Hernandez Sherwood can be reached at firstname.lastname@example.org. Her reporting was supported by the Dennis A. Hunt Fund for Health Journalism, and administered by the California Endowment Health Journalism Fellowships, a program of the University of Southern California's Annenberg School for Communication & Journalism.