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.

The grant is scheduled to be announced Thursday at the first conference of the National Center, which is happening Thursday and Friday at the Sheraton Society Hill in Philadelphia.

The Camden Coalition has been trying to understand how social factors, such as access to food, transportation, housing, and even interactions with the criminal justice system, affect health, Brenner said.

The group has long used hospital claims data from Cooper, Lourdes, and Virtue to find the so-called superutilizers of health care. But now the Camden Coalition has added three years of criminal justice and other data to get a broader picture.

"We found, for instance, 200 patients who are dual systems high utilizers," meaning they are  frequently in jail and regular patients in the hospitals, Brenner said. "These are folks who are expensive and complicated in every one of these systems."

The next step is a pilot program to contact medically complex inmates the day they leave prison and "start to wrap services around them," Brenner said.

The Camden Coalition work involves legal contracts, politics, and heavy-duty data analysis.

"All that stuff is complicated," Brenner said. The Aetna grant is "going to allow us to create curriculum to be able to teach through the National Center other communities how to do this."

Garth Graham, president of the Aetna Foundation, said other parts of the country could benefit from the strategy.

"We find what Dr. Brenner has done very successfully that is not mirrored in many places is the ability to integrate the data well," Graham said. "There are other programs where folks might realize that housing might be one driver and really focus in on the housing aspect. But what Dr. Brenner and his folks have done is really look at the full gamut."

The foundation will receive $350,000 for the first year, to develop the curriculum. If that is successful, an additional $1.3 million allow the Camden Coalition roll the curriculum out to other places.

"What we hope is that the template will be effective, so that other cities and counties might be able to move a little bit faster, but also be able to pay attention to the local case," Graham said.

The Camden Coalition has already worked with the nonprofit Patient Care Intervention Center in Houston, which has a similar approach to data integration and care coordination.

But the Houston group works in very different circumstances, its president David Buck, said. "We have about 130 hospitals with no coordination. You can imagine that's a very different climate," he said. All the Houston-area hospitals handle their own care coordination for superusers of health care, he said.

"That has strengths and weaknesses. There's no perfect solution. It's only a solution that works in a given community," Buck said.