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John Lewis Brenner

From Wikipedia, the free encyclopedia

John Lewis Brenner
John Lewis Brenner 1899.jpg
Member of the U.S. House of Representatives
from Ohio's 3rd district
In office
March 4, 1897 – March 3, 1901
Preceded byPaul J. Sorg
Succeeded byRobert M. Nevin
Personal details
Born(1832-02-02)February 2, 1832
Wayne Township, Montgomery County, Ohio
DiedNovember 1, 1906(1906-11-01) (aged 74)
Dayton, Ohio
Resting placeWoodland Cemetery
Political partyDemocratic
ProfessionTobacco dealer

John Lewis Brenner (February 2, 1832 – November 1, 1906) was a farmer, nurseryman, businessman and member of the United States House of Representatives from Ohio.

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  • ✪ A Conversation with Jeffrey Brenner

Transcription

>>> GOOD AFTERNOON AND WELCOME TO HUD. I AM SO EXCITED TO BE HERE TODAY WITH DR. JEFF BRENNER AND I THINK YOU WILL SEE VERY SOON WHY IT IS AND I AM CONFIDENT YOU WILL SHARE MY EXCITEMENT BY THE TIME WE ARE DONE TODAY. I DON'T THINK THAT ANY SINGLE PERSON IN AMERICA HAS SO CRYSTALLIZED THE IMPORTANCE OF THE RELATIONSHIP BETWEEN HEALTH AND HOUSING AS DR. BRENNER AND HIS TEAM IN CAMDEN, NEW JERSEY, NO PRESSURE. WE HAVE A FAIR NUMBER OF PEOPLE FROM HUD AND GREAT TO HAVE YOU HERETO. ONE OF OUR GOALS IS TO HELP RAISE THE DIALOGUE IN HUD ABOUT THE RELATIONSHIP BETWEEN HOUSING AND HEALTH AND TO UNDERSTAND SOMETHING ABOUT WHAT IS HAPPENING IN THE HEALTHCARE SYSTEM THAT IS OUT THERE OR DOWN THE STREET, HOWEVER YOU THINK ABOUT IT. WE ALSO HAVE GUESTS FROM HHF AND WE ARE CONSTANTLY TRYING TO MAKE SURE OUR FRIENDS AT HHF UNDERSTAND THE FUNDAMENTAL ROLE HOUSING STABILITY PLACE IN IMPROVING THE HEALTH OF OUR RESIDENTS BUT HEALTH OF PEOPLE WHO DON'T HAVE A HOME. SO VERY GLAD TO HAVE MEMBERS OF HHS HERE. I THINK WE MIGHT HAVE SOME FOLKS FROM OTHER AGENCIES, I KNOW THE INTERAGENCY COUNCIL ON HOMELESSNESS, SOME PEOPLE FROM BUDGET AND STAFF PERSON FROM SENATOR BOOKER'S OFFICE, THE NEW JERSEY SENATOR. WELCOME TO EVERYBODY WHO IS HERE TODAY AND I SIMPLY WANT TO SAY THAT WHEN I FIRST READ THE ARTICLE "THE HOT SPOTTERS" IN THE "NEW YORKER" I WAS READING ABOUT THE INTERVENTION DR. BRENNER TALKS ABOUT, WHEN THEY IDENTIFIED THE PATIENTS THAT WERE THE HIGHEST COST TO THE CAMDEN HEALTHCARE SYSTEM AND TALKED ABOUT THE LEVEL OF ENGAGEMENT AND THE WAY THEY ENGAGED PEOPLE IN THINKING DIFFERENTLY ABOUT THEIR HEALTH, I THOUGHT TO MYSELF THIS ENGAGEMENT STRATEGY SOUNDS EXACTLY LIKE WHAT WE HAVE LEARNED IN THE LAST 20 YEARS ENGAGING PEOPLE WHO HAVE LIVED ON THE STREETS FOR A LONG TIME. BUT IN ORDER TO ENGAGE PEOPLE TO APPROACH THEIR LIFE AND CARE AND HEALTH DIFFERENTLY, YOU CAN'T DO IT FROM WITHIN YOUR BOX OR WITHIN YOUR SILO, YOU HAVE TO GO OUT AND GET INTO PEOPLE'S LIVES AND FIND OUT WHAT IS GOING ON WITH THEM, YOU HAVE TO FIND OUT WHAT HAPPENS TO THEM. SO TO BE ABLE TO TRANSLATE THAT EXPERIENCE INTO WHAT IS ONE OF THE HOTTEST TOPICS IN HEALTH REFORM RIGHT NOW, I WANT YOU TO HAVE THE EXPERIENCE OF HEARING FROM DR. JEFF BRENNER. PLEASE GIVE HIM A WARM HUD WELCOME. [APPLAUSE] >> THANK YOU FOR THAT INTRODUCTION. THANK YOU SO MUCH, IT'S SUCH A PLEASURE TO BE HERE TODAY AND I'M REALLY LOOKING FORWARD TO LEARNING FROM ALL OF YOU IN THE ROOM. I'M A FAMILY DOCTOR, MY VISION FOR MY LIFE WAS TO WORK IN AN UNDER SERVED COMMUNITY AND AFTER RESIDENCY I MOVED FROM DOWNTOWN SEATTLE TO DOWNTOWN CAMDEN, LIVED THERE EIGHT YEARS AND WORKED ON FRONT LINE, SAW KIDS, DELIVERED BABIES AT THE LOCAL HOSPITAL AND DID LOTS OF HOME VISITS. I LIKE HAVING A FOCUS GROUP OF ALL THE FAILURES IN UNDER SERVED COMMUNITIES BECAUSE IF THERE IS A FAILURE IN THE CRIMINAL JUSTICE SYSTEM, EDUCATION, YOU QUICKLY FIND OUT ABOUT IT AS YOUR PATIENTS COME IN AND SHARE THEIR STORIES. I WANT TO START BY SHOWING YOU LET'S SEE, SHOWING YOU MY OFFICE, YOU GET A SENSE OF WHAT I DID AND WHERE I WORKED. THIS WAS A SMALL THREE EXAM ROOM OFFICE IN AN AREA CALLED EAST CAMDEN. IT WAS A BEAUTIFUL OFFICE, THREE EXAM ROOMS, BEAUTIFUL IKEA FURNITURE, ART ON THE WALLS. I SAW PEOPLE THAT WERE MEDICAID MOSTLY, I SPEAK SPANISH SO I TOOK CARE OF A WHOLE SPECTRUM OF LARGE FAMILIES. I WAS HAPPY HERE BUT UNFORTUNATELY THERE IS NO BUSINESS MODEL FOR WHAT I DO AND THAT WILL BE A CORE COMMENT OF WHAT I WILL TALK ABOUT TODAY. MY OFFICE IS CURRENTLY BOARDED UP AND CLOSED BECAUSE MY MEDICAID RATES KEPT FALLING. WHEN I STARTED OUT I MADE ENOUGH TO RUN A BUSINESS AND HAVE THE OFFICE. BY THE TIME I CLOSED I WAS MAKING $19 TO $35 A VISIT AND YOU HAVE TO RUN FROM ROOM TO ROOM TO ROOM TO KEEP THE OFFICE OPEN. WE BUILT NEW WINGS ON ACUTE HOSPITALS, HIRED MORE SPECIALISTS, WE BUILT OUT OUR NICUs SO THERE WAS MONEY IN THE DELIVERY SYSTEM BUT HOW WE ALLOCATED IT AND DID WITH IT WAS TO BUILD BIGGER AND BIGGER ACUTE SERVICES WHILE PRIMARY CARE THROUGHOUT NEW JERSEY AND CAMDEN HAVE MORE AND MORE BOARDED UP OFFICES LIKE THIS. I WOULDN'T BE HERE, IT'S GREAT I'M HERE WITH ALL OF YOU, I WOULD MUCH RATHER STILL BE IN MY PRIMARY CARE OFFICE. URBAN COMMUNITIES RECLAIM THINGS. SO MY OFFICE IS SLOWLY BEING RECLAIMED. IT WOULD BE LIKE HAVING RUINS IN A JUNGLE, SO THE CITY IS SLOWLY RECLAIMING MY BUILDING. THE BACK OF IT IS BURNED OUT AND BOARDED UP AS WELL. LET'S TALK ABOUT HOW I GOT STARTED IN THIS. I LEARNED A LOT FROM COMMUNITY ORGANIZING AND FROM COLLEAGUES THAT RUN A GROUP CALLED CAMDEN CHURCHES ORGANIZED FOR PEOPLE IN CAMDEN. I EARLY ON BEFRIENDED THE LEADERS AND FOUND OUT MY COMMUNITY OF ANGRY DISGRUNTELED DOCTORS WAS VERY DISORGANIZED, WE DIDN'T KNOW EACH OTHER AND DIDN'T KNOW HOW TO WORK TOGETHER. WE PUT SOMETHING TOGETHER CALLED THE CAMDEN CITY HEALTH PROVIDER BREAKFAST GROUP. LITERALLY EVERY COUPLE MONTHS WE GOT TOGETHER, THESE WERE ALL OLDER PRIMARY CARE DOCTORS WHO WORKED FOR MANY YEARS IN TINY OFFICES WHO WERE SLOWLY GOING OUT OF BUSINESS AND BANKRUPT. WE GOT TOGETHER AND FOUND OUT YOU HAVE A LOT IN COMMON, WHEN YOU GET DOCTORS TOGETHER WE MOSTLY SIT AROUND AND COMPLAIN AND THAT'S WHAT WE DID. AFTER THREE YEARS WE FORMED CAM DEN COALITION OF HEALTHCARE PROVIDERS. WE QUICKLY REALIZED SOME OF THE MOST IMPORTANT PEOPLE AT THE TABLE WERE NURSES AND HEALTHCARE WORKERS AND WE NEEDED A BROADER FRAMEWORK. OUR EARLY VERSION WAS JUST SO SAVE OURSELVES AND IT DIDN'T WORK VERY WELL. A BUNCH OF THE PROVIDERS ARE DEAD, THEY ARE OLDER, RETIRED, THEIR OFFICES ARE BOARDED UP. WE DIDN'T SAVE OURSELVES BUT IN THE PROCESS OF THIS WE INVENTED A NEW WAY OF TALKING ABOUT THE PROBLEM AT LEAST. ONE OF THE THINGS WE GOT HOLD OF IS FRONT LINE BILLING DATA FROM THE THREE LOCAL LOSSES. THIS WAS VERY MUCH INSPIRED BY PEOPLE WHO CAME DOWN, WHO HAD REFORMED THE POLICE DEPARTMENT IN NEW YORK CITY, SO DICIPLES WHO CAME TO CAMDEN TO REDO THE POLICE DEPARTMENT. I THOUGHT A LOT OF THE THINGS THEY WERE DOING COULD HELP HEALTH CARE. WE WERE PRODUCING NO OUTCOMES AND SPENDING MONEY WHICH IS THE SAME PROBLEM POLICING IN NEW YORK WAS HAVING AS WELL. SO, WE GOT HOLD OF  WE HAVE THREE EMERGENCY ROOMS, TWO INPATIENT HOSPITALS, ABOUT NOW 15 PRIMARY CARE LOCATIONS IN THE CITY OF CAMDEN, WE ARE 9 SQUARE MILES, 79,000 PEOPLE, WE ARE THE SECOND OR THIRD POOREST CITY IN THE COUNTRY, CURRENTLY THE MOST DANGEROUS CITY, THREE OF OUR MAYORS HAVE BEEN INDICTED FOR CORRUPTION. WE PRODUCED RECORDED MUSIC, PRODUCED RADIO, TELEVISIONS, MOST OF THE SHIPS FOR WORLD WAR I AND WORLD WAR II. CAPITALISM IS A POWERFUL FORCE AND IT CREATES AND DESTROYS AND WE WERE HOLLOWED OUT, WE HAD NO KNOWLEDGE OF OTHER INDUSTRIES TO FALL BACK ON. THE DATA WE GOT HOLD OF WAS UNUSUAL. THIS WOULD BE LIKE TARGET, K MART AND WALMART IN ONE COMMUNITY ALLOWING YOU TO GET ALL THEIR CUSTOMER DATA, PUT IT IN ONE DATABASE AND THEN CONVINCE THE CUSTOMERS TO STOP SHOPPING THERE. AND DISGRUNTLED PEOPLE LIKE ME, FRONT LINE PRIMARY CARE DOCTORS NEVER GET HOLD OF DATA SETS LIKE THIS, THIS IS VERY UNUSUAL. SO WE QUICKLY LEARNED THAT HALF THE POPULATION GOES TO AN EMERGENCY ROOM OR HOSPITAL. WE LEARN THAT SOMEONE HAD ACTUALLY GONE 113 TIMES IN A YEAR. WE LEARNED THAT SOMEONE HAD GONE 324 TIMES IN FIVE YEARS. UP IN THE CITY OF TRENTON THERE IS A HOMELESS WOMAN IN HER 50s WHO WENT 450 TIMES IN ONE YEAR. SHE WENT MORE THAN ONCE A DAY TO THE LOCAL HOSPITALS AND LOCAL EMERGENCY ROOMS. SO FAR TRENTON GETS THE AWARD FOR HAVING THE LEADING HIGH UTILIZER IN THE COUNTRY. IT TURNS OUT THAT WE SPEND  THE NUMBERS HAVE GONE UP, IT'S ACTUALLY $108 MILLION TO HOSPITALIZE CAMDEN RESIDENTS OVER AND OVER AND OVER. AND I WOULDN'T BE HERE TODAY IF I THOUGHT WE WERE SPENDING YOUR TAX DOLLARS WELL. SO, WE ARE SPENDING THE AMERICAN PUBLIC'S TAX DOLLARS VERY, VERY POORLY. AND THERE IS NO NEW MONEY COMING, WE ARE LIVING IN AN AGE THAT IS NOT GOING AWAY AND WE ARE GOING TO HAVE TO HAVE HARD DISCUSSIONS HOW WE ARE SPENDING THAT MONEY. AS A COUNTRY WE SPEND $2.8 TRILLION, WE SPENT 18% OF OUR COUNTRY'S WEALTH ON HEALTHCARE. AS WE LOOK FORWARD INTO THE FUTURE THAT HAS STABLIZED BUT WITH 85 MILLION BABY BOOMERS IN THE MIDST OF RETIRING 10,000 PEOPLE TURN 65 EVERY DAY, WE ARE LOOKING AT A TSUNAMI THAT HUMANKIND HAS NEVER SEEN BEFORE. WE HAVE NEVER LIVED THROUGH TIMES OF HAVING SUCH A LARGE PROPORTION OF OUR PEOPLE AGING. COSTS WILL BEGIN TO GO UP AND MANY OF YOU KNOW THE BULK OF THE LONG TERM DEBT IN AMERICA IS HEALTHCARE, HEALTHCARE AND HEALTHCARE. SO, A BIG CHALLENGE FOR BUSINESS IN AMERICA RIGHT NOW IS INCREASING HEALTHCARE SPENDING, A HUGE CHALLENGE FOR FAMILIES IS HEALTHCARE SPENDING AS WELL. THE GREAT TASK TO TACKLE NOW WE HAVE MADE THE DESIST TOWN COVER MORE PEOPLE IS WHAT ARE WE BUYING AND ARE WE BUYING GOOD CARE AND AFFORDABLE CARE AND WE HAVEN'T ANSWERED THAT QUESTION, IT'S A MUCH HARDER TASK. SO WHEN I LOOK AT $108 MILLION A YEAR WE SPEND IN CAMDEN, WHAT I SEE IN THAT, 1% OF THAT MONEY, $1 MILLION WOULD LIAR FOUR OF ME AND OPEN UP OFFICES. WE ONLY HAVE 16 PRIMARY CARE OFFICES IN CAMDEN, 16 TO 20. THAT WOULD BE A 25% INCREASE IN THE PRIMARY CARE SUPPLY IN CAMDEN. THAT WOULD HIRE, YOU KNOW, PROBABLY 10 OUT REACH NURSES. THAT WOULD HIRE 15 OR 20 COMMUNITY HEALTHCARE WORKERS. I COULD PUT DIABETIC EDUCATION IN EVERY PUBLIC HOUSING SITE IN CAMDEN FOR THAT MONEY AND HAVE SOME LEFT OVER. WE HAVE TO THINK HOW WE SPEND OUR DOLLARS AND CHANGE THE DIALOGUE AND MOVE DOLLARS AROUND. ALL YOU KNOW WHEN YOU MOVE DOLLARS AROUND THERE WILL BE WINNERS AND LOSERS, THIS WILL BE PAINFUL DISCUSSIONS. THE MOST EXPENSIVE PERSON HAS $3.5 MILLION FOR THEIR CARE, THAT WAS MEDICARE PATIENT GOING BACK OVER AND OVER. 31% COST GO TO  90% OF THE COSTINGS TO 20% OF THE PATIENTS. THIS BASIC 80/20 IS TRUE IN EVERY SYSTEM. IF YOU GO INTO A CLASSROOM THERE ARE TWO OR THREE KIDS WHOSE LEARNING STYLES ARE DIFFERENT AND DON'T FIT INTO THE AVERAGE AND ARE DRIVING MUCH OF THE DISCIPLINE. IF YOU GO INTO A SCHOOL THERE ARE A FEW FAMILIES DRIVING MUCH OF THE PROBLEMS AND IN THE PRINCIPAL'S OFFICE. IF YOU GO INTO COMMUNITY THERE ARE A FEW FAMILIES OR KIDS WHO ARE SHOOTING EACH OTHER AND CAUSING PROBLEMS. IF YOU GO INTO HOUSING PROJECTS THERE ARE A FEW TENANTS DRIVING THE PROBLEMS. THE PROBLEMS IN THE HUMAN SYSTEM IS WE DO A TERRIBLE JOB THAT CREATE SYSTEMS THAT PIVOT TO THE COMPLEX NEEDS OF THE OUTLIERS. WE STRUGGLE WITH THE LANGUAGE, THE SYSTEM AND THE DESIGN OF WHAT WE ARE GOING TO DO FOR THE OUTLIERS AND THIS IS TRUE IN HEALTHCARE TOO. IT'S TRUE IF YOU LOOK AT ALL HUD EMPLOYEES AND THEIR DEPENDENTS, A SMALL NUMBER OF HUD EMPLOYEES AND DEPENDENTS ARE DRIVING MOST OF THE HEALTH SPEND IN YOUR POPULATION. IF YOU LOOK AT ANY POPULATION DRAW A LINE AROUND IT, PULL OUT ALL THE HEALTH SPENDING AND HEALTH YOU ILLIZATION YOU WILL FIND THE SAME PATTERN. IN HEALTHCARE WE MARCH ALONG WITH AN ONE SIZE FITS ALL MODEL. I HAVE A HAMMER IN PRIMARY CARE AND IT'S CALLED THE 10 MINUTE PRIMARY CARE VISIT AND YOU GET IT NO MATTER WHO YOU ARE. IF YOU HAVE A HEAD COLD, IF YOU ARE IN A WHEELCHAIR, YOU HAVE RECENTLY HAD OPEN HEART SURGERY, YOU SPEAK SPANISH, YOU DON'T UNDERSTAND ANYTHING THAT HAS HAPPENED TO YOU, YOU HAVE RECENTLY BEEN DISCHARGED FROM THE HOSPITAL, WE DON'T HAVE ANY OF THE RECORDS, ALL YOUR MEDS HAVE BEEN CHANGE, I STILL HAVE THAT 10 OR 15 MINUTE VISIT. IF I STAY IN THAT ROOM MORE TIME I MAY AS WELL LAND THAT PATIENT A $20 THEN A $30 AND THEN A $50 BILL. I'M ESSENTIALLY MAKING A CHOICE TO CLOSE MY OFFICE AND BOARD THE OFFICE UP FOR EVERY MINUTE I STAY IN THE ROOM AND DO THE RIGHT THING. THOSE ARE THE CHOICES. THEY MAKE MORE MONEY TREATING HEAD COLDS THAN SICK PATIENTS. THE WAY HEALTHCARE MAKES MONEY IS BY TAKING THOSE VERY SICK PEOPLE AND RUNNING THEM THROUGH ALL THE EXPENSIVE PARTS OF THE HEALTHCARE SYSTEM WHEN YOU CUT SCANS UP AND HOSPITALIZE THEM. WE PAY FAR MORE PER MINUTE AND PER HOUR IF WE HOSPITALIZE YOUR FAMILY THAN TALK TO SOMEONE. WHEN YOU ARE FRUSTRATED SITTING IN THE WAITING ROOM, WHEN YOU ARE SITTING IN THE EXAM ROOM WHEN ANY DOCTOR RUSHED IN AND RUSHED OUT AND DIDN'T LISTEN TO YOU. THAT IS BECAUSE WE HAVE A DEEP AND PROFOUND BIAS BUILT INTO OUR HEALTHCARE SYSTEM. IF YOU PAY FOR TOO MUCH, YOU WILL GET TOO MUCH OF IT. TOO MANY HOSPITAL BEDS, TOO MANY EMERGENCY ROOMS, TOO MANY SCANNERS, TOO MANY SPECIALISTS, TOO MANY NICU, IF YOU DON'T PAY ENOUGH NO ONE WILL LISTEN TO YOU, YOU WON'T GET AN APPOINTMENT, AND THE PRIMARY CARE PROVIDERS OR CARDIOLOGISTS WILL RUN OUT OF THE ROOM. THEY DON'T MAKE MONEY TALKING TO YOU, THEY MAKE MONEY PUTTING YOU THROUGH THE TESTS. CONVERSATIONS WITH PEOPLE IN AMERICA IN THE HEALTHCARE SYSTEM ARE THE LOST LEADER THAT WE USE TO GET YOU INTO OUR BEDS AND INTO OUR SCANNERS AND ONTO OUR PILLS. THAT'S IT. DEEP PROBLEM. WE ARE THIS FAR INTO THE AFFORDABLE CARE ACT AND WE HAVEN'T HAD THAT CONVERSATION. THE NUMBER 1 REASON TO GO TO AN EMERGENCY ROOM IN CAMDEN WAS HEAD COLDS. THERE WERE 12,000 VISITS FOREHEAD COLDS. 7,000 FOR EAR INFECTIONS, 5,000 FOR ASTHMA AND ON AND ON. THESE COULD VERY EASILY BE TREATED IN MY OFFICE. THESE ARE POOR MOMS AND KIDS WITH MEDICAID CARDS SITTING IN EMERGENCY ROOMS IN CAMDEN FOR TWO, FOUR, CIRCUMSTANCES HOURS WAITING TO BE TAKEN CARE OF. THE CHOICE ARCHITECTURE WE BUILD IS BROKEN. I'VE HEARD MANY PEOPLE SAY POOR PEOPLE LIKE TO SIT IN THE EMERGENCY ROOM. THERE IS A VERY CLEAR CATEGORY OF PEOPLE WHO DO LIKE TO SIT IN THE EMERGENCY ROOM. IF IT'S 10 DEGREES BELOW ZERO AND YOU LIVE INTENT CITY IN CAMDEN AND YOU ARE HUNGRY, THE EMERGENCY ROOM IS A GREAT PLACE TO BE. IF YOU ARE A MOM WITH KIDS AND POOR MIDDLE CLASS OR UPPER CLASS, THE EMERGENCY ROOM IS A MISERABLE PLACE TO BE. MOST POVERTY IN AMERICA IS POOR MOMS AND KIDS. MOST PEOPLE WHO SIT IN EMERGENCY ROOMS ARE NOT UNINSURED, THEY ARE INSURED BUT DON'T HAVE BETTER OPTIONS. EVEN YOU CALL YOUR PRIMARY CARE PHYSICIAN HAVE TO BE ON HOLD, ARGUE TO GET IN. CAN YOU IMAGINE IF YOU WERE ON MEDICAID. I CHALLENGE YOU TO CALL ANY MEDICAID PROVIDER AND SEE WHEN YOU CAN GET IN. IT WILL TAKE YOU A LONG TIME TO GET IN. WE ARE A BIG BELIEVER IN SEGMENTATION. THE HEALTHCARE WORLD USES DATA IN ALL OF THE WRONG WAYS. WE USE DATA IN VERY LINEAR WEAR, WE TALK ABOUT RISK STRATIFICATION. WE TRY TO STRETCH PEOPLE OUT AS IF YOU COULD MAKE A LINE OF PEOPLE FROM SICKEST TO HEALTHIEST. ADVERTISERS WOULD NEVER DO THAT. ADVERTISERS SEGMENT DATA, THEY BREAK IT OUT. THIS IS ONE EXAMPLE OF GEOGRAPHIC SEGMENTATION. HOT SPOTTING IS NOT MAKING MAPS. IT'S TEARING A DATA SET APART AND LOOKING FOR OUTLIERS AND DOING ROOT ASSESSMENT WITH THAT. FUNDAMENTALLY HE WAS SHIFTING THE MANAGEMENT OF THE POLICE DEPARTMENT TO FOCUS ON THE FEW OUTLIERS WHO WERE DOING MOST OF THE CRIMES. HE USED MAPPS. DON'T WALK OUT THINKING HOT SPOTTING IS MAKING MAPS. IT IS ONLY ONE. THIS IS THE MESSIER PART. IF YOU GET A DATA ANALYST THAT BRINGS BACK MEANS AND AVERAGES THEY HAVE DONE THE WRONG THING FOR YOU. THE PEOPLE WHO TELL YOU THE MOST ABOUT A BROKEN SYSTEM ARE THE OUTLIERS. THIS IS A MAP OF THE CITY OF CAMDEN, EMERGENCY ROOM AND HOSPITAL DATA COMBINED TOGETHER INTO ONE DATA SET AND OVERLAYING THE PAYMENTS TO THE HOSPITALS. THIS IS NOT CHARGES, CHARGES ARE THE BILLS THAT ARE SENT OUT, RECEIPTS ARE THE PAYMENTS THAT CAME BACK. THESE ARE REAL DOLLARS THEY WERE PAID TO TAKE CARE OF POOR PEOPLE. THIS IS MOSTLY YOUR TAX DOLLARS AT WORK. THIS IS MOSTLY MEDICAID AND MEDICARE. MAPPING IT OUT OVER FIVE YEARS, IT'S ONLY 9 SQUARE MILE CITY, THE RED AREAS ARE CALLED CENSUS BLOCKS, VERY SMALL GEOGRAPHY. 6% ARE 10% OF THE LAND MASS. 18% OF THE PATIENTS, 27% OF THE VISITS AND 37% OF THE PAYMENTS TO THE HOSPITALS FOR THE CARE OF THOSE PATIENTS. SO, ESSENTIALLY WHAT YOU FIND IN AMERICA AND, FRANKLY, ALL OVER AMERICA EVERYWHERE WE HAVE LOOKED IS HIGH COMPLEX PATIENTS GET COLLECTED INTO SPECIFIC GEOGRAPHIC PATTERNS AND OFTEN LIVE IN BUILDINGS YOU GUYS ARE MANAGING OR YOU IN SOME WAY ARE FUNDING AND I WILL SHOW YOU PROVE OF THAT IN A SECOND. THESE ARE THE TWO MOST EXPENSIVE BUILDINGS IN THE CITY OF CAMDEN. THESE BUILDINGS ARE WELL MANAGED BY IDEALISTIC PEOPLE WHO CARE DEEPLY ABOUT THE POPULATION. THESE ARE NOT STEREO URBAN PUBLIC HOUSING BUILDINGS. THE BUILDING AT THE TOP IS RUN BY SOMEONE CALLED PETER IN FAIR SHARE HOUSING, IT'S A BEAUTIFUL BUILDING CALLED NORTHGATE 2. 600 PATIENTS LIVE IN THE BUILDING, THEY ARE DUAL ELIGIBLE, THESE ARE OLDER, DISABLED, THEY HAD 12 MILLION IN PAYMENTS FOREGOING BACK OVER AND OVER TO THE HOSPITAL. THE BUILDING THE ATHE BOTTOM IS SUBACUTE NURSING HOME WITH 300 PATIENTS WHO HAD $15 MILLION TO GO BACK OVER AND OVER AND OVER. WE SPENT A HUGE AMOUNT OF TIME IN THESE BUILDINGS AND IN BUILDINGS SIMILAR TO THEM ASKING RESIDENTS TO TELL US THEIR STORIES AND WE BROUGHT SOME OF THEM HERE TO MEET YOU TODAY. ANTHONY PHOENIX. ANTHONY? AND ANNA. SO, WHEN YOU ASK ME QUESTIONS I MAY TURN AROUND AND ASK THEM TO ANSWER THE QUESTION. WHAT WE LEARNED IN THE BUILDING IS THAT THESE BUILDINGS COULD BE A 600 MILES AWAY FROM HEALTHCARE. WE HAVE AN ACADEMIC HEALTH CENTER THAT IS RECEIVING INCREDIBLE PUBLIC SUBSIDY ONLY 6 BLOCKS AWAY AND YOU WOULD THINK IT WAS 600 MILES AWAY. WE WILL GET INTO SOME OF THE STORIES IN A BIT. I WILL GIVE YOU A SMALL TASTE OF THINGS WE HAVE SEEN. WE HAD A DIABETIC PATIENT GOING OVER AND OVER TO THE EMERGENCY ROOM WITH HIGH SUGARS. OUR NURSES WENT OUT AND ASKED THE PATIENT TO USE THEIR INSULIN. THE PATIENT PUT A NEEDLE AND PULLED UP 50 CCS OF AIR AND WENT OUT TO INJECT IT INTO HIS ARM. TURNS OUT HE WAS SIGHT IMPAIRED AND DIDN'T SEE WHAT HE WAS DOING. IN FACT IF YOU HAVE PERFECT VISION IT'S HARD. HE WENT TO THE REFRIGERATOR SAID THEY KEEP BRINGING REFILLS AND I CAN'T SEE THEM. YOU DON'T NEED TO BE POOR TO HAVE THESE KIND OF HEALTHCARE FAILURES TO GO ON, IT'S COSTING US A LOT OF MONEY. SO, WE ARE GOING TO FURTHER SEGMENT HERE AND ONE OF THE THEMES IN OUR WORK IN CAMDEN IS BRINGING THE LAST 100 YEARS OF BRILLIANCE IN THE BUSINESS WORLD OF HOW TO THINK ABOUT DOING THINGS MORE EFFICIENTLY AND EFFECTIVELY IN HEALTHCARE. WHAT I AM SOING GO SHOW YOU IS ABOUT THREE TO FOUR YEARS AGO I LITERALLY BROUGHT THIS SLIDE, ANTHONY CAN BACK ME UP, AND STOOD IN THE FIRST FLOOR OF NORTHGATE 2 AND SHOWED THE SLIDE AND IT WAS PROBABLY THE MOST FUNNY HAD EVER HAD BECAUSE IT IS SO RARE WHEN YOU'VE HAD A CHANCE WORKING WITH A DATA SET TO GO OUT AND MEET THE PEOPLE IN THE DATA SET AND I SAID TO EVERY ONE IN THE BUILDING, I DON'T KNOW WHAT IS GOING ON HERE, I HAVE SOME THOUGHTS ABOUT THIS. I'M A FAMILY DOCTOR, I HAVE AN OFFICE, MANY OF YOU KNOW WHO I AM AND I THINK SOMETHING IS PROBING ENAND I WANT TO TELL YOU HOW MUCH OF YOUR HEALTH CARRIES COST. DO YOU GUYS FEEL LIKE YOU GOT $12 MILLION WORTH OF CARE? AND ANTHONY, I THINK EVERY ONE IN THE BUILDING COULDN'T BELIEVE SOMEONE MADE THAT MUCH MONEY AND THEY FELT SO UNWELL AND SO DISRESPECTED. SO, ANTHONY, I'M GOING TO STOP FOR A SECOND, HERE'S YOUR CHANCE, DO YOU WANT TO CHIME IN? >> YOU ARE EXACTLY CORRECT. [ OFF MIC ] YOU RECEIVE $12 MILLION IN HEALTHCARE, HOW MANY PEOPLE FEEL LIKE THEY HAVE RECEIVED $12 MILLION IN HEALTHCARE AND NOT A SOUL IN THAT ROOM RAISED THEIR HAND. I WAS ONE OF THE PEOPLE IN THE ROOM, I DIDN'T FEEL LIKE I HAD AN OPPORTUNITY TO RECEIVE $12 MILLION IN HEALTHCARE OVER THE LAST YEAR. AND I HAD BEEN USING THE EMERGENCY ROOM. BUT  AND I'M SO HAPPY THAT YOU POINTED THAT OUT BECAUSE I REMEMBER THAT DAY THAT YOU CAME IN AND YOU PRESENTED YOUR SLIDE FROM YOUR POWERPOINT AND YOU EXPLAINED ABOUT THE HEALTHCARE BROKEN SYSTEM IN THE CITY OF CAMDEN, I'M SO EXCITED, NOW I'M EXCITED AGAIN TO HEAR YOU CONTINUE ON WITH YOUR STATEMENT, FOLLOW UP ON WHAT YOU STARTED SOME SEVEN TO EIGHT YEARS AGO IF I REMEMBER CORRECTLY. >> FIXING BROKEN SYSTEMS IS A LONG JOURNEY. SO WHAT CAME OUT OF THAT DISCUSSION WAS A WHOLE LOT OF BRAINSTORMING WITH RESIDENTS AND PARTNERING WITH A GROUP CALLED CAMDEN CHURCHES ORGANIZED FOR PEOPLE, USING CLASSIC ORGANIZING TO FIND OUT FROM THE CONSUMERS, THE RESIDENTS, WHAT WAS DRIVING ALL THIS. WE LEARNED A TREMENDOUS AMOUNT, I CAME BACK TO MY STAFF AND I SAID I DON'T CARE WHAT IT COSTS, I WANT US TO THROW EVERYTHING INCLUDING THE KITCHEN SINK TO HELP CHANGE THE SYSTEM AND GET QUALITY CARE. IF YOU CAN'T DO IT IN ONE BUILDING YOU WILL NEVER DO IT IN THE WHOLE COMMUNITY LEVEL. WE DID DIABETIC EDUCATION, WE DID EXERCISE CLASSES, DANCE CLASSES, WE DID ART THERAPY, WE DID GROUP THERAPY, WE DID ANYTHING WE COULD THINK OF. ONE OF OUR BOARD MEMBERS WHO IS A PRIVATE MEDICARE PRACTICE AGREED TO OPEN A TWO EXAM ROOM ON THE FIRST FLOOR THINKING LET'S BRING EVERYTHING TO THIS BUILDING BECAUSE IN THE END PEOPLE JUST NEED TO COME DOWN THE ELEVATOR AND THIS WILL BE WHAT FIXES THE PROBLEM. SO NOW THREE YEARS LATER AND I CAN TELL YOU WE STILL HAVEN'T FIGURED IT OUT. SO, IT TURNS OUT THAT WE KNEW IN DATA TERMS, WE KNEW THE NUMB RATER, WE DIDN'T KNOW THE DENOMINATOR. I KNEW HOW MANY PEOPLE WERE GOING TO THE HOSPITAL, I DIDN'T KNOW HOW MANY PEOPLE WEREN'T GOING TO THE HOSPITAL. THAT TURNS OUT TO BE EVEN MORE IMPORTANT, SO LET ME SHOW YOU WHY. THIS IS A SEGMENTATION CONCEPT, BREAKING OUT INTO FOUR CATEGORIES THE FOLKS THAT LIVER IN THE BUILD GD AND THROUGH OUR COLLABORATION WITH THE BUILDING WE WERE ABLE TO GET THE LIST OF EVERY ONE WHO LIVES IN THE BUILDING AND MATCH IT TO THE BUILDING DATA AND MATCH IT TO THE HOSPITAL DATA, THAT IS VERY UNUSUAL. AND WHAT WE LEARNED IS THAT PEOPLE FALL INTO BASICALLY FOUR CATEGORIES, THIS IS CLUSTER ANALYSIS, NONLINEAR WAY OF THINKING ABOUT THE DATA. THERE ARE PEOPLE WHO NEVER OR VERY RARELY GO TO THE EMERGENCY ROOM, THERE ARE MEDIUM EMERGENCY ROOM UTILIZER WHO HAVE TWO OR THREE EMERGENCY VISITS A YEAR. THERE ARE HIGH EMERGENCY ROOM WHO HAVE 8 VISITS AND ONE INPATIENT AND VERY HIGH WHO HAVE THREE INPATIENT AND ONE ED. THESE ARE THE SUB GROUPS IN THE BUILD WITHING. ALL THE BLUE ARE THE FOLKS WHO NEVER OR RARELY GO TO THE EMERGENCY ROOM OR HOSPITAL. THE HIGHEST COST, MOST COMPLEX HOT SPOT IN THE CITY OR ONE OF THEM, THE VAST MAJORITY OF THE PEOPLE IN THE BUILDING AREN'T USING IT BUT THERE'S A HOT SPOT IN THE HOT SPOT. CAN YOU IMAGINE PROCTOR AND GAMBLE DOING WHAT I HAD JUST DONE? WHEN PROCTOR AND GAMBLE, WHEN WALMART, WHEN THE ENGINES OF CAPITALISM WANT TO FIGURE OUT HOW TO MEET YOUR NEEDS, YOU THE CUSTOMER, THEY SEGMENT THE MARKETPLACE. THE CLOTHES THAT YOU ARE WEARING, HIS THE CAR YOU DROVE TO WORK, THE FOOD YOU SHOPPED FOR YESTERDAY ARE NOT ACCIDENTS. SOMEONE KNOWS EXACTLY WHAT YOUR TASTES ARE, WHAT YOU LIKE TO BUY AND THEN THROUGH VERY CAREFUL THOUGHT THERE IS A FACTORY THAT DELIVERS HIGHLY PRECISE PRODUCTS, VERY HIGH QUALITY AND RELATIVELY LOW COST TO EXACTLY YOUR DEMOGRAPHIC SEGMENT SO THAT YOU GET YOUR NEEDS MET. WE DON'T DO THAT IN HEALTHCARE. IN MY PRIMARY CARE OFFICE I HAD A JUNGLE OF PEOPLE AND I DELIVERED A DISORGANIZED JUMBLE OF SERVICES EVERY DAY THAT WERE UNRELIABLE AND SOME DAYS WHAT I DID WAS AMAZING AND A LOT OF DAYS WHAT I DID WAS MEDIOCRE AND IT WAS EXHAUSTING AND IT WAS UNSUSTAINABLE. SO WE NEED TO USE THE TOOLS OF CAPITALISM, SEGMENTATION, SO THIS IS NONLINEAR, THEY DON'T LIKE THIS, YOU HAVE TO DEVELOP A HYPOTHESIS, ANALYSIS AND THEN YOU HAVE TO TALK TO EVERY ONE AND SAY DOES THIS MAKE SENSE? THEN REFINE YOUR HYPOTHESIS. SO WHAT WE FOUND OUT IS THAT THERE WERE 122 PEOPLE, 20% OF THE PEOPLE WERE MEDIUM EMERGENCY ROOM UTILIZER, EMERGENCY ROOM VISITS, A THOUSAND DOLLARS, THAT'S NOT THAT EXPENSIVE. 3% WERE HIGH EDU; 21 PATIENTS WERE HIGH INPATIENT UTILIZER. THERE WERE 15 FOLKS IN THE BUILDING THAT WERE DRIVING MUCH OF THE COST AND MUCH OF THE YOU LIE DISASSOCIATION BUT THEY ARE ISOLATED, THEY DON'T COME OUT OF THEIR ROOMS, THEY ARE NOT GOING TO PARTICIPATE IN OUR PROGRAMS, THEY ARE IN AND OUT OF THE HOSPITAL, THEY FEEL ISOLATED, SCARED, ALONE AND OUR TRADITIONAL METHODS OF REACHING THEM AREN'T GOING TO WORK. THESE ARE YOUR CHRONICALLY HOMELESS PATIENTS WHO HAVE BEEN LIVING ON THE STREETS FOR YEARS AND YEARS AND YOUR DATA SET, YOUR EXTREME OUTLIERS, HARD TO REACH, THESE ARE A SIMILAR GROUP THAT YOU HAVE TO USE DIFFERENT METHODS AND DIFFERENT WAYS OF THINKING AND DIFFERENT MENTAL MODELS TO FIGURE OUT HOW TO REACH THEM, TOUCH THEM, ENGAGE THEM. WE ARE STILL FIGURING IT OUT. WHAT WE DECIDED TO DO, ONE OF OUR KEYS IS A HEALTH EXCHANGE, EVERY DAY DATA STREAMS IN, WE GET RADIOLOGY, HOSPITAL DISCHARGE, I KNOW IN REALTIME ANYTIME ANYONE IS ADMITTED TO THE HOSPITAL AND WHERE THEY ARE FROM. WE DEPLOY OUR NURSES TO THE BEDSIDE TO MEET THEM AND FOLLOW THEM BACK OUT. WE HAD THE WRONG TOOL FOR THE WRONG JOB. THE FIX WASN'T NECESSARILY A PRIMARY CARE OFFICE, IT WAS A NURSE COORDINATION SPECIALIST MEETING YOU AND TRACKING YOU OUT. THERE IS NOTHING WRONG WITH A PRIMARY CARE OFFICE IN A BUILDING LIKE THIS CONCEPTUALLY. A COUPLE THINGS, IF YOU ARE OLDER, SICKER, MORE DISABLED, YOU PROBABLY HAVE A PRIMARY CARE PROVIDER FOR YEARS, EVEN IF THEY ARE HARD TO GET IN TO SEE AT LEAST YOU KNOW THEM. GETTING PEOPLE WHO ARE SICK TO SWITCH THEIR PRIMARY CARE PROVIDER IS A HUGE CHALLENGE. IT MAKES SENSE. THAT'S LIKE CALLING UP YOUR GRANDMOTHER OR MOM AND TRYING TO GET THEM TO SWITCH PROVIDERS. OLDER PEOPLE DON'T LIKE TO CHANGE. THE PROBLEM IS EVEN IF EVERYBODY SWITCHES TO THE BUILDING PRIMARY CARE PHYSICIAN THERE ISN'T A BUSINESS MODEL. THERE AREN'T ENOUGH PEOPLE TO SUSTAIN A FULL TIME OFFICE, UP HAVE PART TIME STAFF, WHO WANTS TO GO TO PART TIME STAFF? THERE ARE A LOT OF CHALLENGES TO DOING THIS. SO, THE FURTHER WAYS OF DOING SEGMENTATION, THIS IS LOOKING IN THE ENTIRE CITY OF CAMDEN AT THE TOP 1% OF HIGH INPATIENT UTILIZER, IT'S 200 PATIENTS, BREAKING THEM OUT IN CATEGORIES. UNDERSTANDING WHERE THEY LIVE AND THE DRIVERS. THIS IS DIFFERENT IN HOW WE TYPICALLY USE HOME HEALTHCARE DATA. WE HAVE TAKEN A SIMILAR ANALYTIC FRAME AND BEGUN TO LOOK AT OTHER DATA SETS AROUND THE COUNTRY. FIRST I WANT TO TELL YOU ALL THE DATA I'M SHOWING YOU FOR THE LAST 10 YEARS HAS LIVED ON TWO $50 HARD DRIVES WITH OPEN SOURCE INDESCRIPTION, PASS WORD PROTECTION SITTING INSIDE OF A $100 SAFE UNDER A DESK USING A DESK TOP COMPUTER WITH MICROSOFT ACCESS AND A REALLY TALENTED 25 YEAR OLD. SO, THIS IS BIG DATA, RIGHT? BIG DATA DOESN'T MEAN BIG VENDOR COSTS. SO, HOW WE DID THE DATA IS WE BUY EXPENSIVE SYSTEMS AND SPEND LOTS OF MONEY ON VENDORS. THIS IS NOT EXPENSIVE STUFF AT ALL. THIS IS LOOKING AT NEWARK'S DATA, COLLECTING DATA FROM THE LOCAL HOSPITALS IN NEWARK FOUND THE SAME TYPE OF THINGS. THIS IS UP IN MAINE, WE GOT HOLD OF COLLABORATING WITH THE STATE OF MAINE A FEW COUNTIES DATA SETS AND MAPPED IT OUT AND TURNED OUT THE HIGH COMPLEX PATIENTS MAPPED DOWN TO CERTAIN BUILDINGS. THEY WOULDN'T LET US SHOW YOU BUT THERE ARE BUILDINGS THIS MAPPED OUT TO. IT TURNS OUT WHEN YOU LIVE IN A SMALL TOWN YOU CAN'T LIVE IN THE MIDDLE OF KNOW WHERE. WE RANKED BY THE PERCENTAGE OF HIGH UTILIZER OF THOSE LIVING IN TOWNS. THEY ARE NOT TAKING CARE OF THE MOST VULNERABLE CITIZENS WELL. THESE ARE INDICATORS OF DISORGANIZATION AND FRAGMENTATION IN THEIR SERVICE DELIVERY OF THE GAPS BETWEEN HOUSING, THEIR CHURCHES AND HOW THEY KNIT THEIR SOCIAL FAB LIKE TOGETHER. SO, THIS COULD BE YOUR MOM OR YOUR GRANDMOTHER OR A FAMILY MEMBER, THIS IS A CAT SCAN OF A PATIENT WHO IS MIDDLE CLASS, WHO WENT OVER AND OVER TO A FIVE HOSPITAL HIGHLY INTEGRATED DELIVERY SYSTEM THAT IS COMPLETELY CONIC HAD BY ELECTRONIC HEALTH RECORDS. THIS PATIENT WENT BACK AND HAD 54 ADMISSIONS OVER A COUPLE YEARS, 73 CAT SCANS OF THE HEAD. 143 CAT SCANS. THIS PATIENTS LIFETIME RIDE IATION RISK IS INCREASED  RADIATION RISK IS INCREASED. THIS IS NOT A POVERTY STORY. YOU THOUGHT YOU WERE COMING TO HERE ABOUT THE POOREST CITY IN AMERICA BUT THIS IS ABOUT OUR HEALTHCARE, HOW WE HAVE CONSTRUCTED THE SYSTEM, HOW WE TRAIN OUR PROVIDERS, HOW WE SEPARATE AND RUINED BEHAVIORAL HEALTH AND ADDICTION, HOW WE TOOK OUT SOCIAL WORK AND DISEMPOWERED IT. THIS IS THE IN HE'S WE HAVE CREATED 85 MILLION BABY BOOMERS ARE HEADED FOR. IT TURNS OUT THIS PATIENT JUST HAD ANXIETY AND A GROUP OF FAMILY DOCTOR TRAINEE'S HOT SPOTTED, FOUND THIS. THEY HAVE A PSYCHOLOGIST GOT INVOLVED AND WORKED WITH THE PATIENT AND THE PATIENT STOPPED GOING TO THE EMERGENCY ROOM AND GETTING SCANS. HEALTH I.T. IS NOT GOING TO FIX THIS. ACOs ARE NOT GOING TO FIX THIS. THE AFFORDABLE CARE ACT IS NOT GOING TO FIGURE IT OUTCOME COMPLETELY, IT'S HEADED IN THE RIGHT DIRECTION. THIS IS A DEEP CULTURAL PROBLEM HOW WE PUT THE SYSTEM TOGETHER AND EVEN THE LANGUAGE AND WORDS WE ARE USING. I WANT TO GIVE YOU AN EXAMPLE OF A CASE, THE KIND OF PATIENTS WE WORK WITH. THIS IS A 55 YEAR OLD MALE LIVING IN A HIGH RISE, HAD 9 EMERGENCY ROOM AND 6 INPATIENT, 12 MEDICINES A DAY, HAS KIDNEY FAILURE, KIDNEY KENSER, BLOCKAGES IN ARTERIES. SEVERE BACK PAIN. THIS IS THE PATIENT IN THE MIDDLE AND THESE ARE ALL THE SERVICES THAT ARE NOT CONNECTING WITH THE KIND OF PATIENT. PATIENT WAS PICKED UP BY THE TEAMS IN HOSPITAL 1, WENT OUT TO SUBACUTE REHAB, WENT TO HOSPITAL 2, NEEDED TO COORDINATE DIALYSIS, TRANSPLANT, PRIMARY CARE PROVIDER HAD TO COORDINATE PAIN MANAGEMENT, GI, UROLOGY, ONCOLOGY AND SURGERY. WE SHOULD BE REALLY PROUD OF THIS. THIS IS A SIGN OF SUCK SIS OF THE BIO MEDICAL ACT. THE SUCCESS OF BIO MEDICAL ACT. ALL THAT CREATED THE INFRASTRUCTURE OF AMERICA THAT CAN DO THINGS FOR PEOPLE AND SAVE LIVES, THIS IS THE GRAPH OF IT, THIS IS THE VISUAL REPRESENTATION OF IT. THE PROBLEM IS WE HAVEN'T CAUGHT UP TO WHAT WE CREATED. ALL THAT COMPLEXITY, WE HAVEN'T CAUGHT UP TO HOW WE MANAGE, COORDINATE, PRIORITIZE, WE HAVE A LOT OF WORK TO DO TO CATCH UP TO THE GREAT THINGS WE FUNDED AND CREATED. NONE OF THESE CIRCLES ARE TRAINED IN A WAY TO TALK TO ONE ANOTHER. OUR LAWS DON'T ALLOW THE DATA TO MOVE AROUND EASILY. OUR PAYMENT MODELS DISCOURAGE COLLABORATION. WE WILL PUT THEM OUT OF BUSINESS IF YOU COLLABORATE THE WAY YOU WANT THEM TO. THESE ARE THE CRAZY PILES OF MEDICINE IN HOMES. THIS IS THE PATIENT, GLENN, HIS PRIMARY CARE PROVIDER WORKS ON A FEDERALLY HOSPITAL CENTER. THIS IS KORIN WHO WORKED WITH US AS A HEALTH COACH, WORKED WITH HIM CLOSELY, HELPED NAVIGATE, A COMPANY HIM AND WALK THROUGH THE HEALTHCARE SYSTEM AND ON THE RIGHT IS JASON WHO WORKS CLOSELY WITH KORIN. WE HAVE 12 AMERICORPS THAT WORK WITH US, THEY ARE MY SECRET WEAPONS TO ONE DAY FIX HEALTHCARE. SO, THIS IS ONE OF YOUR PATIENTS, SO, SOMEWHERE DOWN THE LINE A DOLLAR COMING FROM HUD HAD A HUGE IMPACT ON THIS PATIENT'S LIFE. THIS IS A 58 YEAR OLD PATIENT WHO LET US SHARE HIS STORY WITH YOU, MID I CAID COVERED, HOME LESS FOR 20 YEARS, LACKS FAMILY SUPPORT, CAN'T  OBVIOUSLY CAN'T MANAGE MEDS, LOTS OF CHALLENGES IN HIS LIFE, ASTHMA, HIGH BLOOD PRESSURE, HIGH CHOLESTEROL, DEPRESSION, OUR TEAMS MEET THE PATIENTS IN THE HOSPITAL, FOLLOW THEM OUT, IN THIS CASE TO THE SHELTER, WORK WITH ALL THE SERVICES, WE DON'T WANT TO DUPLICATE THE SERVICES, WE WANT TO PULL THE SERVICES TOGETHER AND WE MANAGED TO GET THIS PERSON INTO A MODEL FIRST MODEL AND LET ME SHOW YOU WHAT HAPPENS. SO THIS IS THE PATIENT'S CLAIMS DATA FROM THE THREE LOCAL HOSPITAL. THE FIRST STAR IS WHEN THE PATIENT WAS ENGAGE. ON THE LEFT WAS THE NUMBER OF HOSPITALIZATION THAT MONTH, SO AS YOU WALK ALONG THESE ARE TICK LINES SO THE PATIENT HAD TWO VISITS IN A MONTH. THE RED LINE ARE INPATIENT  I'M SORRY, THE MONTHS DIDN'T COME OUT ON THIS. THIS IS ABOUT AN ONE YEAR PERIOD THAT YOU ARE LOOKING AT HERE. WE ENGAGE THE PATIENT AND THE HOSPITALIZATION WENT UP. WHEN WE FINALLY GOT THE PATIENT INTO HOUSING THE HOSPITALIZATION WENT AWAY. SO, I DON'T THINK I NEED TO TELL EVERY ONE IN THE ROOM HERE HOUSING IS THE BEST PILL. IT'S THE BEST SCAN. IT'S MORE POWERFUL THAN SURGERY. YOU KNOW, IF WE ARE NOT HOUSING THESE PATIENTS THEY WILL GET SICKER, OLDER AND DIE AND COST A LOT OF MONEY IN THE PROCESS. WE ARE WASTING SO MUCH MONEY. I KNOW THERE ARE SO MANY IMPEDIMENTS OF LOOKING AT THESE BUCKETS OF MONEY AND SEEING HOW THEY AFFECT EACH OTHER BUT THAT'S WHAT WE NEED TO DO. WE HAVE INHERITED OBSOLETE SYSTEMS IN EDUCATION, IN HOUSING, IN HEALTHCARE, IN POLICING AND THE JOB OF ALL US IN THE ROOM IS MODERNIZING THESE SYSTEMS, WE ARE FAR BEHIND IN DOING THIS. THIS IS THE DATA THAT COMES OUT EVERY DAY THROUGH THE HEALTH INFORMATION EXCHANGE. THIS IS CITY WIDE CONSENSUS. I WANT TO CLOSE WITH THE LAST SLIDE. OUR THEORY OF CHANGE IN OUR WORK AND I THINK PROBABLY PEOPLE LIKE DENNIS COLHANE AND OTHERS WHO ARE TRYING TO FIX SYSTEMS ARE PROBABLY USING SIMILAR THEORIES, BUT YOU NEED THREE THINGS TO FIX BROKEN THINGS IN HEALTHCARE, YOU HAVE TO HAVE A DEEP ENGAGEMENT. FOR US IT'S COMMUNITY, IT'S DIFFERENT WAYS OF THINKING AND ENGAGING WITH PEOPLE, WITH SYSTEMS, WITH STAKEHOLDERS, WITHIN SYSTEMS. IT'S REDESIGN. THIS IS BOX BY BOX REDESIGN OF WORK FLOW, THIS IS LEAN THINKING. THIS IS WHAT MANUFACTURING DID TO BECOME MORE EFFICIENT AND EFFECTIVE AND LOTS AND LOTS OF DATA MOVING AROUND IN REALTIME. WE ARE PRETTY FAR AWAY FROM PULLING ALL THAT OFF. DOING ALL THREE OF THOSE THINGS SIMULTANEOUSLY IS INCREDIBLY CHALLENGING AND I THINK THE TASK AS WE GO FORWARD. LET ME STOP THERE AND TAKE SOME QUESTIONS. [APPLAUSE] >> IF YOU WANT TO RAISE YOUR HAND OR PLEASE COME UP TO THE MIC IF YOU HAVE QUESTIONS. AND LET US KNOW WHO YOU ARE, PLEASE. >> THANK YOU. YOUR DISCUSSION RELATES TO CAMDEN, CONTIGUOUS OR NEARBY IS MOUNT LAUREL. ACROSS THE RIVER TO THE WEST IS THE CITY OF PHILADELPHIA. AND OVERARCHING IS CAMPBELL SOUP. WHAT DID YOU FIND WITH RESPECT TO FREQUENCY OR VALUE OF SERVICES THAT ARE PROVIDED IN CAMDEN THAT ARE NOT PROVIDED NEXT DOOR IN MOUNT LAUREL WHERE THEY ARE SEEKING HOUSING? >> SO, LET ME FILL IN A FEW GAPS AND PROBABLY YOU ALL KNOW THIS HISTORY BETTER THAN I DO WHICH IS MOUNT LAUREL WAS THE LITIGANT AS PART OF A FAMOUS DECISION CALL THE MOUNT LAUREL DEVISION WHICH THEY WERE USING ZONING TO DISCRIMINATE. THE IMPACT WAS A SUPREME COURT WHICH ENED IN SET ASIDE MONEY FOR HOUSING. THE HOUSING IS BEAUTIFUL AND THE MANY PATIENTS THAT I HAVE THAT LIVE OUT THERE AND STAFF EVEN ENDED UP WITH MUCH BETTER QUALITY OF LIFE AND LOTS OF OPPORTUNITY. THE ISSUE ABOUT GEOGRAPHIC CONCENTRATION OF SERVICES, I'VE HEARD MANY PEOPLE IN CAMDEN SAY IT'S UNFAIR THAT CAMDEN HAS THE BURDEN OF HOUSING SERVICES FOR THE HOMELESS, BEHAVIORAL SERVICES AND THEY ARE BEING DUMPED ON BY SIX COUNTIES AWAY. MY RESPONSE HAS ALWAYS BEEN YEARS AND YEARS AGO CAMDEN WAS THE EPICENTER OF CULTURE, COMMERCE, TRANSPORTATION, SERVICES, IDEAS AND IF YOU WANT TO RETURN TO BEING THE EPICENTER OF THOSE THINGS THEN IT'S OKAY TO BE THE EPICENTER OF THE BEST BEHAVIORAL HEALTH SERVICES IN THE REGION BUT LET'S ALSO BE THE EPICENTER OF LOTS OF GREAT IDEAS, EDUCATION, SO I THINK INHERENT IN YOUR COMMENT IS REALLY ABOUT ARE OTHER MUNICIPAL 'TIS PROVIDING SERVICES AND DO THEY HAVE GEOGRAPHIC SERVICES, WE COULD DEBATE IT BUT THERE ARE A CERTAIN CATEGORY OF PEOPLE THAT PROBABLY BENEFIT FOR DENSER COLLECTION OF SERVICES TO BE ABLE TO ACCESS THE SERVICES. IT'S HARD TO IMAGINE A RECENTLY RELEASED OFFENDER LIVING IN AN EXTREMELY ISOLATED SPOT NOT BEING ABLE TO MOVE AROUND, YOU KNOW. I THINK THESE ARE MUCH BIGGER QUESTIONS THAN WHAT I'M ADDRESSING, BUT YOUR QUESTION IS VERY GERMANE AND AN IMPORTANT QUESTION, PROBABLY BIGGER THAN I COULD ANSWER. >> ONE ASPECT OF YOUR ANSWER THAT I WAS SEEKING COMMENT ON IS THE ROLE OF THE CORPORATE EMPLOYER IN OTHER COMMUNITIES WHERE THEY PROVIDE OR ASSIST IN PROVIDING HOUSING. >> I THINK CORPORATION'S JOB IS TO MAXIMIZE THEIR PROFITS, SERVE THEIR SHAREHOLDER'S NEEDS AND THEN BE GOOD CORPORATE CITIZENS IN THAT ORDER AND THAT'S WHAT THEY ARE. BECAUSE IF THEY DON'T DO THAT THEY GO OUT OF BUSINESS. I THINK IT'S THE JOB OF GOVERNMENT TO ANSWER THE CITIZENRY AND MEDIATE BETWEEN CORPORATIONS AND CITIZENRY AND THAT SYSTEM BROKE DOWN IN CAMDEN. WE HAVEN'T HAD GOOD GOVERNANCE AND THERE'S BEEN AN IMBALANCE OF POWER. I THINK IT'S VERY UNFAIR TO PUT THE BURDEN OF WHERE CAMDEN IS RIGHT NOW ON ANY SPECIFIC CORPORATION OR HOLE THE DUTY OF THAT CORPORATION TO BE ANYTHING MORE THAN FRANKLY THE DUTY OF NEW JERSEY AND THE DUTY OF THE FEDERAL GOVERNMENT. THE BIGGEST FAILURES IN CAMDEN IS HOW PUBLIC SERVICES THAT ARE CURRENTLY RECEIVING FUNDING ARE DELIVERED IN INADEQUATE WAYS THAT ARE POORLY ORGANIZED AND THAT'S NOT THE FAULT OF CAMPBELL SOUP, IT'S THE FAULT OF CITY AND STATE GOVERNMENT. WE JUST FIRED OUR ENTIRE POLICE DEPARTMENT, IT'S THE BEST THING WE EVER DID IN CAMDEN AND THEY HAD TO REAPPLY FOR THEIR JOBS. >> GOOD AFTERNOON, THANK YOU FOR YOUR TALK, DR. BRENNER. I'M AN EMERSON HUNGER FELLOW IN THE DEPARTMENT OF HEALTH AND HUMAN SERVICES AND MY QUESTION IS ABOUT THE WORK THAT YOU MIGHT HAVE DONE TO ENGAGE COMMUNITY BENEFITS SPENDING, TO SUPPORT THE WORK YOU ARE DOING OR CAN YOU SPEAK TO THE POTENTIAL FOR COMMUNITY BENEFITS TO SUPPORT THE WORK? >> SO, THAT'S A GREAT QUESTION, AND BUILT INTO THE QUESTION IN AFFORDABLE CARE ACT PEOPLE HAVE TO REPORT THEIR COMMUNITY BENEFIT SPENDING AND DO A COMMUNITY ACCESSMENT NEEDS PLAN. I WISH IT WAS THAT EASY TO FIX THE HEALTHCARE SYSTEM, IT'S IDEALISTIC, IT WAS A NOBLE IDEA BUT HOSPITALS HAVE TO PAY THEIR BILLS AND THE WAY THEY PAY THEIR BILLS BASED ON THE RULES WE CREATED IS TO FILL THEIR BEDS AND THE WAY THEY FILL THEIR BEDS IS BY HAVING BIG EMERGENCY ROOMS THAT ARE WELL LIT THAT CAN GET LOTS OF PEOPLE IN THEM. AND THEY ARE LIKE THE AIRLINE INDUSTRY AND HOTEL INDUSTRY WHICH THEIR PROFIT MARGIN IS BASED ON OCCUPANCY RATES. THE PROFIT MARGIN OF THE HOSPITAL AGENCY IS RAZOR THIN. IF YOU WANT TO INVEST IN A BUSINESS, HOSPITALS ARE NOT VERY PROFITABLE BUSINESSES SO I THINK IT'S PUTTING AN UNDUE BURDEN ON HOSPITALS TO FIX THIS BECAUSE ONE PART OF GOVERNMENT IS SAYING FIX IT, THE OTHER PART OF GOVERNMENT HAS BUILT A PAYMENT SYSTEM AND FUNDED A PAYMENT SYSTEM, THE ONLY WAY THEY CAN STAY IN BUSINESS IS FILL THEIR BED. YOU ARE ASKING THEM TO GO EXTINCT. YOU ARE PUTTING A GUN TO THEIR HEAD SAYING WE WANT YOU TO SPEND YOUR MONEY TO EMPTY YOUR BED. WE WANT YOU TO SPEND MONEY TO GO OUT OF BUSINESS. THAT'S ESSENTIALLY WHAT WE HAVE ASKED THEM TO DO WITH THE COMMUNITY BENEFIT 990. I HAVE HEARD WE NEED A REVERSE BURTON HILL ACT. WE HAVE TOO MUCH CAPACITY. WE COULD PROBABLY CLOSE A THIRD OF THE HOSPITALS IF WE DID THIS RIGHT, MAYBE EVEN MORE BUT IT'S LIKE BASE CLOSINGS. EVERY COMMUNITY FIGHTS TO KEEP THEIR HOSPITAL OPEN BECAUSE OF JOBS. THANK YOU FOR THE QUESTION, I THINK IT'S A VERY REASONABLE ONE, I DON'T THINK COMMUNITY BENEFITS AND 990s ARE GOING TO GET US WHERE WE WANT TO BE. >> THANK YOU. >> WE HAVE A QUESTION FROM THE FIELD. PEGGY JOHANSON. FIRST SAID MY FRIEND MARCIE SAID TO LISTEN TO YOU BECAUSE YOU KNOW WHAT YOU ARE TALKING ABOUT. SHE ASKED AS WE IN HUD OFFICES WORK TO REVITALIZE AN AREA, WHAT DO YOU SEE THE ROLE OF THE HEALTHCARE SYSTEM TO BE, SHOULD WE ENCOURAGE MEDICAL CARE CLINICS TO OPEN IN THE AREAS OR FOCUS ON OTHER UNDUST EVERY AS FAR AS TRANSPORTATION TO HEALTHCARE SYSTEMS IS RELIABLE. >> WHAT IS MOST INTERESTING IS I DON'T HAVE ANSWERS TO THE QUESTIONS AND I DON'T THINK YES ONE DOES AND YET YOU HAVE THE NIHs IN D.C., YOU HAVE A RESEARCH OFFICE. OUR WORK IS EXPERIMENTAL WORK. THIS IS DEEP R AND D AND IT'S KIND OF SCARY TO THINK THAT WE ACTUALLY DON'T KNOW HOW TO DELIVER BETTER CARE AT LOWER COST BUT IT'S TRUE. LET ME SAY IT AGAIN. WE DON'T KNOW HOW TO DELIVER BETTER CARE AND LOWER COST BUT WE SPEND 18% OF OUR ECONOMY DELIVERING CARE. SO I THINK WE ARE WAY BEHIND ON SOME REALLY ELEMENTAL QUESTIONS. I'LL GIVE YOU A SMALL EXAMPLE. THE WHOLE HEALTHCARE INDUSTRY, THE INSURANCE COMPANY'S MODEL HAS BEEN TO USE PREDICTIVE MODELING GUESS WHO IS GETTING SICKER AND THEN HAVE A NURSE IN A CUBBIBLE CALL THEM ON THE PHONE. I WONDER HOW NURSES CALLING HOMELESS PEOPLE WILL WORK. WHY WE NEED MODELING WHEN SICK PEOPLE ARE LAYING IN HOSPITAL BEDS, I HAVE FOUND THEM EASILY WALKING UP AND DOWN THE HALL. WE DON'T NEED FANCY PREDICTION TO FIND OUT WHERE THE SICKEST PEOPLE ARE, THEY ARE ACTUALLY SPENDING TIME IN THE HOSPITAL. WE BELIEVE THAT YOU GET MOST OF THE SAVINGS FROM WORKING WITH THE SICKEST PATIENTS AND BRINGING THEM DOWN TOWARD WELLNESS RATHER THAN WORKING WITH HEALTHY PEOPLE WHO ARE GETTING SICKER. THERE ARE A LOT OF PEOPLE WHO PREFER TO WORK WITH HEALTHY PEOPLE, THEY ARE EASIER, THEY ARE COOPERATIVE, SHOW UP. IT'S HARDER TO WORK WITH SICK PEOPLE. >> I DON'T KNOW IF YOU WILL HAVE AN ANSWER TO THIS EITHER, I'M LINDA, IN MY LIFE OUTSIDE OF HUD I WORK WITH WHAT USED TO BE A FREE MEDICAL CLINIC. AND IT WAS FOR 20 YEARS IT'S BEEN VOLUNTEER DOCTORS AND VOLUNTEER NURSES AND A VERY FINITE NUMBER OF PATIENTS, THAT'S THE PROBLEM, IT WAS A CLOSED LIST OF PEOPLE WHO WOULD BE SERVED. WE ARE NOW GOING TO BE A MEDICAID PROVIDER WITH THE DESIRE TO HAVE A FULL TIME NURSE, BUT FROM WHAT I'M HEARING WE MAY NOT BE ABLE TO AFFORD  WE WON'T BE DOING WHAT WE HAVE BEEN DOING WHICH IS PROVIDING GOOD MEDICAL CARE. DO YOU HAVE ANY OTHER HOPE. >> THE ANSWER IS YES. YOU ARE RIGHT WE NEED TO CHANGE OUR PAYMENT MODEL IN HOW WE PAY FOR STUFF, WE NEED TO REDISTRIBUTE DOLLARS. WE WILL CLOSE HOSPITALS AND SHIFT DOLLARS FROM INPATIENT BED BACK INTO THE COMMUNITY. DOES THAT SOUND FAMILIAR? OTHER SYSTEMS HAVE HAD THAT PROBLEM FROM ACUTE CARE TO COMMUNITY BASED SERVICES. WE WILL ALSO SHIFT DOLLARS FROM SPECIALTY CARE AND VERY TECHNICAL SERVICES BACK TOWARD PRIMARY CARE AND EVEN BEYOND PRIMARY CARE TO OLD SCHOOL COMMUNITY NURSING AND SOCIAL WORK. WE WILL SHIFT MONEY FROM MEDICAL TO BEHAVIORAL HEALTH AND ADDICTION SPENDING AND WE WILL FURTHER SHIFT MONEY I THINK TOWARD HOUSING SPENDING AS WELL IF WE DO IT RIGHT. THOSE ARE THE BROAD TRENDS IN ALL THIS. GETTING FROM HERE TO THEORY THINK MAKES ME WANT TO GO HIDE IN CAMDEN. >> HI, JEFF. I'M FROM THE HEALTH SERVICES ADMINISTRATION, I'M THE CHIEF MEDICAL OFFICER FOR THE BUREAU OF PRIMARY HEALTHCARE, WE RUN THE COMMUNITY HEALTHCARE PROGRAM. WE HAVE NOW 1300 ORGANIZATIONS WE FUND THAT OPERATE CLOSE TO 10,000 CLINICS ACROSS THE UNITED STATES. 240 OR SO OF THESE GRANTEES PROVIDE HEALTHCARE FOR THE HOMELESS, ONLY 60 PROVIDE HOUSING PRIMARY CARE IN HOUSING DEVELOPMENTS. ONE OF THE CHALLENGES THAT WE ARE FACING IS HOW DO YOU PARTNER FAMILY HEALTHCARE IN HOUSING, AND THE CHALLENGES ARE SOMETIMES BUREAUCRATIC, SOMETIMES SORT OF PERSONAL AND INTERPERSONAL. IF WE ARE ABLE TO GET MORE HEALTH CENTERS PARTNERING WITH HOUSING DEVELOPMENTS AND HOUSING PROGRAMS, YOU TALKED ABOUT SORT OF A COALESCE ENDS OF CERTAIN PROGRAMS AND SERVICES, WHAT ARE THE MOST ESSENTIAL SER STLAISES NEED TO BE TOGETHER WITH PRIMARY CARE. >> SO, THERE'S A WONDERFUL BOOK CALL THE HEALTHCARE PARADOX THAT WAS JUST WRITTEN BY RESEARCHERS IN HARVARD, IT'S OBVIOUS ONCE I SAY THIS. IF YOU LOOK AT ALL DEVELOPED COUNTRIES IN THE WORLD AT THEIR HEALTHCARE SPENDING WE ARE WAY ABOVE THE AVERAGE. IF YOU LOOK AT SOCIAL SERVICE SPENDING WE ARE BELOW. IF YOU COMBINE THEM AND ADD UP MEDICAL SPENDING AND SOCIAL SERVICE, WE ARE IN THE MILL. IF YOU MAKE A RATIO OF THE TWO AND ASK HOW MUCH DO WE SPEND ON MEDICAL CARE TO SOCIAL COMPARED TO THE OTHER COUNTRIES, WE ARE WELL OFF THE CHART. WE ARE MEDICALIZING HUMAN PROBLEMS. WHAT ARE REALLY BEHAVIORAL HEALTH WE ARE MEDICALIZING. THIS ISN'T ROCKET SCIENCE, THERE ARE PEOPLE ALL OVER THE COUNTRY DOING INCREDIBLE WORK ABOUT INTEGRATION OF THE SERVICES, THERE ARE SO MANY BARRIERS TO THIS THAT YOU GUYS IN GOVERNMENT WILL HAVE TO SOLVE. A SMALL TASTE OF THIS IS THE STATE LICENSING WHAT IT WOULD TAKE TO GET AN EXTENSION OF YOUR FEDERALLY QUALIFIED HEALTH CENTER INTO PUBLIC HOUSING HAS TO DO WITH SQUARE FOOTAGE, I ALSO THINK MANY ARE TOO SMALL AND MANY HOUSING AGENCIES ARE TOO SMALL, MANY OF OUR ADDICTION CENTERS ARE TOO SMALL. WE ARE GOING TO SEND A MESSAGE YOU NEED TO CONSOLIDATE AND HAVE SCALE IN SIZE. IT'S HARD TO PARTNER IF YOU DON'T HAVE THE FIXED COST AND INFRASTRUCTURE TO EVEN KEEP THE LIGHTS ON. SO MOM AND POP SHOPS IN HEALTHCARE ARE KIND OF AN ANTIQUETED NOTION AND SHOULDN'T MAKE IT INTO THE FUTURE. THERE'S NO WAY A LITTLE OFFICE WITH THREE EXAM ROOMS CAN GIVE YOUR FAMILY THE WELL ORGANIZED HEALTHCARE YOUR FAMILY NEEDS. I DON'T THINK A SMALL HOUSING AGENCY CAN PULL OFF HOUSING FIRST, I DON'T THINK A SMALL ADDICTION FACILITY CAN MODERNIZE AND GIVE CARE. THERE ARE THINGS YOU CAN MESSAGE OUT ALL THESE MOM AND POP THINGS NEED TO MERGE AND CONSOLIDATE. EVERY TIME YOU PARTNER IT'S PRETTY HARD TO WORK, RIGHT? YOU HAVE TO HAVE A LOT OF INFRASTRUCTURE AND PROJECT MANAGE THAT PARTNERSHIP AND MOVE IT BEYOND INTENTION. I THINK THOSE ARE SMALL PIECES. >> GREAT, THANKS. >> WE HAVE ANOTHER QUESTION FROM MARA BLITZER, SHE SAID I'M WONDERING ABOUT THE BUILDING SPECIFIC HOT SPOT ANALYSIS YOU GAVE AS AN EXAMPLE. WHAT STEPS DID IT TAKE TO GET THE DATA YOU NEEDED TO IDENTIFY THE PEOPLE MOST IN NEED OF HEALTH INTERVENTIONS AND ARE THERE PRIVACY OR COORDINATION ISSUES. >> HIPAA IS NOT AN IMPEDIMENT, IT'S A CULTURAL IMPEDIMENT BUT NOT LEGAL IMPEDIMENT. WHEN PEOPLE DON'T WANT TO WORK WITH YOU THEY USE HIPAA BUT WHEN THEY DO WANT TO WORK WITH YOU, HIPAA IS NOT A PROBLEM. IT TOOK ME A LITTLE WHILE TO REALIZE THAT. SO, HIPAA SAYS THAT YOU CAN FIND VERY SPECIFIC KINDS OF LEGAL AGREEMENTS WHERE YOU'VE GOT SPECIFIC KINDS OF PURPOSES TO DO THAT FOR SPECIFIC REASONS TO DATES ASHARE AND NOTHING YOU HAVE SEEN TODAY, I DIDN'T BREAK THE FEDERAL LAW. I'M HERE TO TELL YOU I DIDN'T BREAK THE FEDERAL LAW. SO, YOU KNOW, THE IMPEDIMENTS TO THIS ARE OFTEN TRUST, RELATIONSHIP BUILDING, AND LONGEVITY. I'VE BEEN IN CAMDEN 15 YEARS, IT TAKES A LOT OF TRUST FOR SOMEONE TO TURN OVER THEIR DATA TO YOU. YOU GUYS ARE SITTING ON ALL THIS DATA, YOU COULD HAVE DONE WHAT I DID YEARS AGO. WE WOULD LOVE IF SOME OF YOU WOULD SHARE SOME OF YOUR CAMDEN HOUSING DATES AWITH US SO WE COULD FIGURE OUT HOW THIS WORKS. I'M EXTENDING AN ARM TO ALL THE DATA PEOPLE HERE TO HELP ME FIGURE OUT HOW TO FIND A BUSINESS ASSOCIATED AGREEMENT WITH HUD TO DO DATA SHARING TO MORE COMPREHENSIVELY FIGURE THIS OUT IN CAMDEN. >> DR. BRENNER, THANK YOU SO MUCH, I'M WITH THE U.S. AGENCY ON HOMELESSNESS. I DON'T WORK AT HUD SO I DON'T HAVE ANY DATA FOR YOU. I APOLOGIZE IF I WAS DISTRACTING YOU, I WAS JUMPING UP AND DOWN IN MY SEAT. THIS IS VALID ATING FOR THOSE OF US TRYING TO END HOMELESS, HOW HOUSING IS PARTS OF THE SOLUTION. I THINK WHAT I TAKE AWAY IS THE SOLUTION MAY BE COMPRISED OF THEE THINGS, GOOD QUALITY HEALTHCARE AND DIAGRAM WITH ALL THE CIRCLES HELPS THAT, HOUSING IS PARTS OF THE SOLUTION BUT I THINK THE THIRD PART, CONVERSATIONS BE, ENGAGING PEOPLE. WE HAVE A STRATEGY FOR PAYING FOR THE HEALTHCARE, PAYING FOR HOUSING THAT INVOLVES A LOTS OF THIS BUILDING. WE DON'T HAVE A STRATEGY FOR PAYING FOR THE CONVERSATIONS, THE KEY PART OF THE SERVICES THAT I THINK ARE REALLY IMPORTANT. I WONDER HOW DO WE BRING THIS IDEA AND INTERVENTION TO SCALE IF WE CAN'T FIGURE OUT HOW TO PAY FOR IT. >> IT'S A GOOD QUESTION. IT'S A QUESTION OF ENGAGEMENT WHICH IS, YOU KNOW, WE HAVE AN OBSOLETE MENTAL MODEL WHAT WE DO FOR HEALTHCARE, HOUSING, EDUCATION AND ALL THESE FIELDS. HOW DO WE ENGAGE EACH OTHER AND A NEW DIALOGUE. THAT WILL BE A PUBLIC DIALOGUE. FUNDAMENTALLY THE ONLY WAY TO SOLVE THIS KIND OF PROBLEM IS TO CIVICALLY ENGAGE AND HAVE A PUBLIC DIALOGUE BECAUSE IN THE END WE MAKE THE RULES HOW WE WANT TO LIVE. WE WILL INCREASINGLY BE HURT BY THE RULES AND THE SYSTEMS WE'VE CREATED. THE FIRST STEP IS EVEN REAL IDEASING THERE'S A PROBLEM AND WHAT THE PROBLEM IS. RIGHTS NOW WET DON'T EVEN AGREE IN HEALTHCARE ON WHAT THE PROBLEM IS. LIKE I THINK THAT WHAT I'VE SAID TODAY IS, YOU KNOW, A VERY CLEAR FRAMING OF THE PROBLEM WITH LOTS OF CLEAR EXAMPLES, BUT WE'VE HAD A LOT OF PLEAD I ACOVERAGE, WE'VE HAD A LOT OF DISCUSSION ABOUT HEALTHCARE BUT IT ALWAYS SEEMS LIKE NOT QUITE THE RIGHT PROBLEM WE TALKED ABOUT. I LIKEN IT TO GO TO A CAR DEALERSHIP AND YOU SPEND TWO HOURS WITH YOUR SPOUSE TALKING TO THE PERSON TELLING YOU ABOUT THE DIFFERENT WAYS YOU CAN FINANCE THE CAR AND YOU ARE ARGUING, NO, I DON'T WANT TO PAY THIS PERCENT, I WANT A 36 MONTH LEASE, NOT 30, AND YOU GET WORKED UP AND GET IN YOUR CAR AND YOU ARE KIND OF MAD AND DON'T KNOW WHY YOU ARE MAD ANYMORE AND YOU ARE DRIVING AWAY AND YOU SAID, OH, MY GOD, WE FORGOT TO LOOK AT THE CARS. WHAT DO WE WANT TO BUY. >> WE ARE SPENDING A LOT OF MONEY, WE NEVER HAD A DISCUSSION WHAT WE WANT TO BUY. WHAT DOES GOOD HEALTHCARE LOOK LIKE AND WHAT DO YOU WANT TO BUY? WHAT DOES GOOD HOUSING LOOK LIKE AND WHAT YOU WANT TO BUY. >> WE WILL NEVER CHANGE THE RULES UNLESS WE CHANGE OUR VISION OF WHAT GOOD CARE LOOKS LIKE AND HOUSING AND HEALTHCARE. >> DR. BRENNER, I WORK AT HUD AND I DONE HAVE DATA FOR YOU EITHER. BUT I DO HAVE THE EXPERIENCE IN WORKING WITH LOW INCOME POPULATION IN PUBLIC HOUSING AND SOME OF THE ISSUES YOU'VE SPOKEN ABOUT ARE ISSUES WE ALSO ADDRESS BUT I WANT TO CUT TO THE CHASE ON ANOTHER LEVEL AND THAT IS SOCIAL IMPACT BONDS. HOW WOULD YOU PACKAGE IT, IF YOU WERE TRYING TO SELL THE IDEA OF WHAT YOU DO TO THE PRIVATE MARKET TO BE USED IN PUBLIC HOUSING AUTHORITIES SO THAT RESIDENTS COULD WORK WITH PHYSICIANS AND HOSPITALS TO DO THE KIND OF WORK WE ARE TALKING ABOUT. WHAT WOULD THE STEPS LOOK LIKE? >> FOR THOSE WHO DON'T KNOW SOCIAL IMPACT BONDS ARE THE IDEAS OF HAVING OUTSIDE INVESTORS BRING CAPITAL IN TO HELP FUND THE START UP OF A SERVICE. IF IT STAYS, THEY ARE ABLE TO CAPTURE A PORTION OF IT BACK. THE LANGUAGE OF A BOND REQUIRES YOU KNOW WHAT YOU ARE DOING. AND I'M GOING TO SAY IT HERE PUBLICLY, WE DON'T KNOW WHAT WE ARE DOING IN CAMDEN, WE ARE A R AND D SHOP AND WE ARE WAY OUT ON A LIMB EXPLORING NEW STUFF. HOPEFULLY IN A YEAR I WILL BE ABLE TO GIVE YOU A MUCH BETTER SENSE OF WHAT THE RETURN ON INVESTMENT WOULD BE. I WOULD NEVER BUY A BOND FOR SOMETHING WHERE YOU HAVE NO IDEA WHAT THE RETURN ON INVESTMENT IS AND THAT IS KIND OF TRUE WITH A LOT OF THINGS SOCIAL IMPACT BOND IS BEING DISCUSSED. SOME OF THE STUFF IS CUTTING EDGE STUFF WHERE WE DON'T KNOW NECESSARILY WHAT THE RECIDIVISM RATE IS FOR PRISON. YOU HAVE TO KNOW WHAT THE DATA IS, THE INTERVENTION, YOU'VE HAD MANY TRIALS OF DELIVERING IT. THE EXPECTATION OF THE WORD "BOND" IS A TABLE THING. I THINK WE ARE WAY BACK UP THE CHAIN, THIS WOULD BE LIKE A PENNY STOCK. >> [ OFF MIC ] >> LOOK, I THINK WE HAVE TO GET CAPITALISM INTO THIS. CAPITALISM SKILL IS BETTER THAN THE NONPROFIT COMMUNITY. THERE IS A ROLE FOR PUBLIC PRIVATE. WE WERE TALKING AT LUNCH, MY FAVORITE PUBLIC PRIVATE IS CDC PARTNERING WITH A PRIVATE HOUSING DEVELOPER AND THERE'S A GOOD BALANCE OF POWER THERE AND THE CDC PLAYS THE ROLE OF PLANNING THE PROJECT, SECURING THE LAND, MAKING ALL THE PARTNERSHIPS, WORKING WITH THE COMMUNITY AROUND THE COMMUNITY BENEFIT AND THE PRIVATE DEVELOPER DOES WHAT IT DOES WELL WHICH IS PUT UP HOUSING. SOMEHOW WE DON'T DO THAT WELL WITH THINGS LIKE MEDICAID TRANSPORTATION, WITH MEDICAID MANAGED CARE, OUR OTHER VENDOR MODELS ARE NOT GOING AS WELL AS THAT MODEL. >> DR. BRENNER, I'M PAUL, I'M A NEPHROLOGIST AT NIH, YOU HAVE ALREADY DISSED THESE TWO THINGS AND I'M STILL STANDING AND YOU ARE STILL SMILING. I THINK IT WOULD BE USEFUL FOR PEOPLE WHO ARE IN POLICY AND PHYSICIANS, YOU SPENT A BEAUTIFUL AMOUNT OF TIME TALKING ABOUT INEQUALITY OF DISTRIBUTION OF SERVICES AND WE HAVE SIMILAR PROBLEM WITH IN COME I'VE HEARD ABOUT, SO IT'S A RESONATING IDEA. THE HEALTHCARE SYSTEM UNDERWENT 40 YEARS AGO, WE CHANGE THE SYSTEM OF PSYCHIATRIC HOSPITALS TO COMMUNITY HEALTH SERVICES AND WE PUT A LOT OF I THINK VERY ILL PEOPLE INTO THE STREETS, INTO HOMES, INTO COMMUNITIES AND WE DON'T HAVE GOOD SYSTEMS LIKE WITH TB CARE TO ENSURE THERE IS MEDICATION ADHERENCE. AND I LIKED YOUR ANALYSIS FOCUSING ON THAT 1% OF THE 1/10%, YOU MUST KNOW HOW MANY HAVE A PSYCHIATRIC DIAGNOSIS BECAUSE I THINK THAT'S THE CRITICAL THING, GOING TO THE EMERGENCY ROOM MAY BE BECAUSE IT'S WARM, BUT YOU DON'T DO IT IN THE SUMMER BUT YOU MIGHT GO 400 TIMES A YEAR BECAUSE YOU HAVE A SEVERE PSYCHIATRIC DIAGNOSIS. BY THE WAY, I THINK THE CAT SCAN WAS ABNORMAL. >> IT WAS. THERE WERE 79 ABNORMAL. SO, A COUPLE OF GREAT QUESTIONS THERE AND SORT OF ELEMENTS. ONE IS WE HAVE BEEN HERE BEFORE IN BEHAVIORAL HEALTH, OUR COLLEAGUES  ONE THIRD OF STATE BUDGETS WERE PSYCHIATRIC HOSPITALS AT ONE POINT AND BECAUSE OF AGITATION OF PATIENTS AND THEIR FAMILIES AND LAWSUITS AND GROWING RECOGNITION IT WAS NOT A GOOD MODEL, WE PLAYED THE DECISION TO DEINSTITUTIONALIZED PSYCHIATRIC CARE AND WE ARE ABOUT TO DO IT IN HEALTHCARE. I THINK THE GROUP HAS MADE A BEAUTIFUL WAY OF CLEANING THAT UP. I THINK IT IS A MODEL FOR EVERYTHING WE NEED TO DO ON THE MEDICAL SIDE. OUR TEAM OUT REACH PROGRAM LOOKS IDENTICAL TO AN ACT TEAM WHICH IS HIGH RISK WRAP AROUND MODEL. IT ALSO LOOKS LIKE A PACE PROGRAM WHICH IS FOR GERIATRIC HIGH RISK. WE HAVE LOTS OF THE WRAP AROUND HOUSING MODELS, WHEN YOU PULL THEM APART THEY LOOK SIMILAR, THEY HAVE A LOT OF SIMILAR ELEMENTS TO THEM. THE OTHER PIECE I WANT TO CALL OUT IS HOW MANY OF YOU ARE AWARE OF LITERATURE FOR ADVERSE CHILD HOOD EXPERIENCE? THE SAME NUMBER OF HAND IN EVERY ROOM I'VE BEEN IN RAISE EXCEPT HOSPITAL EXECUTIVES HAVE NOT HEARD OF ANY OF THIS AND DOCTORS HAVEN'T HEARD OF IT BUT SOCIAL WORKERS, NURSES AND SOME OF YOU GUYS. THIS IS EXTREMELY IMPORTANT WORK THAT HAS NOT BEEN TALKED ABOUT AT ALL. IT STEMS BACK FROM A STUDY DONE BY A GUY VINCE, A PHYSICIAN, HE SENT OUT A SURVEY TO 17,000 MIDDLE CLASSED PATIENTS THAT WERE KAISER PATIENTS. 70% RETURNED IT, THAT IS HIGH, AND HE ASKED THEM ABOUT THE HORRIBLE STUFF THAT HAPPENED TO THEM IN THEIR CHILDHOOD. DEATH OF A PARENT, SEXUAL ABUSE, PHYSICAL ABUSE, AND WOULD THEY LET IT BE ATTACHED TO THEIR HEALTHCARE RECORDS. MORE THAN 50% OF THE BABY BOOMER POPULATION HAD AT LEAST ONE OF THESE THINGS, IT DIDN'T TELL YOU HOW MANY TIMES IT HAPPENED BUT THEY HAD ONE OF THOSE THINGS HAPPEN AND IT PREDICTED BETTER THAN ANYTHING WE'VE EVER FOUND AN INCREDIBLE ARRAY OF VARIABLES. HEALTH SPENDING, HEALTH YOU ILLIZATION, SMOKING, ALCOHOLISM, SUBSTANCE ABUSE, POORLY CONTROLLED CHRONIC ILLNESS, EARLY PREGNANCY, A WHOLE VARIETY OF VARIABLES. UNDERLYING THIS IS IF YOU EXPOSE A CHILD INUTERO OR AS A SMALL CHILD THEY ARE REWIRED. IT'S A FORM OF PERMANENT BRAIN DAMAGE, THE THINGS YOU'VE DONE TO THEM AND YOU HAMPER THEM THE REST OF THEIR LIVES AND THOSE ARE YOUR FOLKS YOU SEE AS CHRONICALLY HOMELESS THAT ARE THE HARDEST TO REACH. THE WIRING IN THE SYSTEMS OF BUILDING TRUST AND STABLE RELATIONS WITH PEOPLE HAVE BEEN PERMANENTLY DAMAGED. SO, THE ONE THING THAT LINKS ALL OF OUR SOCIAL SYSTEMS TOGETHER IS THIS HYPOTHESIS AND I'VE HEARD A VERY TALENTED PERSON NAMED SANDRA BLOOM, WHO YOU SHOULD INVITE IN THE FUTURE, WHO SAID THIS IS AS IMPORTANT AS THE GERM THEORY BECAUSE IT LINKS EVERY PART OF HUD TOGETHER WITH HHS AND OTHER PARTS OF GOVERNMENT BECAUSE WE ARE DEALING WITH A PROFOUNDLY LARGE GROUP OF PEOPLE, DEEPLY DAMAGED AS CHILDREN AND GO IN DIFFERENT DIRECTIONS. SOME GO TO CRIMINAL JUSTICE, COME TO HUD, SOME END UP IN THE EMERGENCY ROOM IN HOSPITALS OVER AND OVER, IN HHS, IT DON'T MEAN THEY WORK FOR HUD  [LAUGHTER] THANK YOU FOR THE COUPLE OF POINT YOU MADE. >> [ OFF MIC ] >> IT'S INTERESTING, IT'S ALL OVER THE COUNTRY WHAT WE ARE FINDING IS THERE IS A PLACE IN THE WORLD FOR SCHIZOPHRENICS THAT A LOT OF OUR FOLKS HAVE ACTUALLY PERSONALITY DISORDERS WHICH ARE LIFE LONG IMPAIRMENTS THAT ARE INCREASINGLY BEING RECOGNIZED AS OUT GROWTHS OF EARLY LIFE TRAUMA. AND THEY OFTEN GET MISDIAGNOSED AS BIPOLAR AND GET QUIETED DOWN WITH BENZOS AND ANTIPSYCHOTICS BECAUSE IT WILL TONE THEM DOWN. THANK YOU FOR THE QUESTION. >> I'M PETER ASHLY IN THE OFFICE  HUD'S OFFICE OF HEALTHY HOMES, THANKS FOR BEING WITH US TODAY. MY FIRST QUESTION IS WHAT DO YOU THINK THE POTENTIAL IS OF THE MEDICAL HOME CONCEPT UNDER THE AFFORDABLE CARE ACT FOR DELIVERING HIGHER QUALITY, MORE INTEGRATED CARE? THE SECOND QUESTION IS YOUR THOUGHTS ON COMMUNITY HEALTH WORKERS. WE HAVE HAD SOME GRANTS FOR ASTHMA INTERVENTIONS IN HOMES, WE FOUND THEM TO BE QUITE EFFECTIVE AT A LOWER COST AND COMMUNICATE A LOT OF TIMES WITH THE RESIDENTS BETTER THAN OTHERS. >> LET ME TAKE THE SECOND ONE FIRST BECAUSE IT'S REALLY EASY. TREMENDOUS AMOUNTS OF THIS WORK CAN BE DELEGATED AND IT'S POWERFUL WHEN YOU DELEGATE IT TO PEOPLE WITH DEEP FAMILIARITY WITH COMMUNITIES AND FAMILIES AND CIRCUMSTANCES, THAT IS AN INCREDIBLY POWERFUL MODEL THAT WET DON'T KNOW IN AMERICA HOW TO FULLY FIGURE OUT. IT'S HARD TO SCALE THEM BUT WE NEED TO FIGURE THAT OUT AND RUN THEM. BUT WE HAVE SEEN THE POWER OF IT IN OUR WORK AND MANY OF OUR COLLEAGUES AROUND THE COUNTRY HAVE SEEN THE POWER OF IT AS WELL. YOU CAN DEFINITELY HIRE EXPENSIVE NURSES AND SOCIAL WORKERS AND HAVE THEM DO THIS. YOU NEED THEIR WISDOM BUT A LOT OF THE FOLLOW UP WORK CAN BE DELEGATED, WITH HE NEED TO FIGURE OUT HOW TO BUILD TEAMS AND TEAMS ARE COMPLICATED, HARD TO BUILD. THE SECOND PART IS HARD TO ANSWER BECAUSE IT'S MY TRIBE THAT CAME UP WITH THE IDEA OF PATIENTS IN THE MEDICAL HOME. IT CAME OUT OF PEDIATRICS AND FAMILY MEDICINE LATER EMBRACED IT. THE PROBLEM WITH PATIENT IN A MEDICAL HOME IS WE RUSHED IT OUT OF THE LAB WITHOUT HAVING ANY IDEA WHAT WE WERE DOING. THEN WE SLAPPED A STANDARD ON IT WITHOUT ANY IDEA WHAT WORKED AND THEN WE CERTIFIED IT AND THEN WE CREATED A PAYMENT MODEL FOR IT WITHOUT ANY IDEA WHAT WE WERE PAYING FOR. THAT IS A BIG PROBLEM, RIGHT? SO LET ME BE CLEAR. IF YOU LOOK AT THE LIST OF BROAD LIVEABLES IT'S MORE QUALITY CARE, TOTALLY ON THE SAME PAGE BUT HOW THEY ACTUALLY IMPLEMENT IT, YOU COULD BE A LEVEL 3 MEDICAL HOME, PATTING YOURSELF ON THE BACK GETTING A BUMP OF $3 PER PERSON PER MONTH WHICH ISN'T ENOUGH TO DO ANYTHING AND STILL DELIVERING THE STILL CRAPPIEST CARE RUNNING FROM ROOM TO ROOM TO ROOM IGNORING YOUR SICKEST PATIENT. IT IS SHOWN IT DOESN'T INCREASE CARE. A PATIENT SHOULD WAKE UP IN THE MOMENT AND YOUR ENTIRE OFFICE IS DIFFERENTLY, EVERY WORK FLOW ARE SO PROFOUNDLY DIFFERENT YOU WOULDN'T EVEN RECOGNIZE IT. THAT IS DISRUPTIVE CHANGE. PATIENTS IN A MEDICAL HOME WAS POORLY IMPLEMENTED INCREMENTAL CHANGE. >> HI, I'M BILL, I'M AN ECONOMIST IN POLICY DEVELOPMENT AND RESEARCH. I HAVE A QUESTION THAT WAS TOUCHED ON BY A COUPLE OTHER PEOPLE WHICH IS WHAT FRACTION OF THE BENEFITS THAT YOU ARE GETTING BY IMPLEMENTING YOUR SYSTEM WOULD YOU ATTRIBUTE TO BETTER PROVISION OF MENTAL HEALTH SERVICES? >> SO, WE DON'T HAVE THAT DATA. THE ONLY THING I HAVE RIGHT NOW IS DATA FROM HOSPITALS SO I HAVE INPATIENT SPENDING AND I HAVE EMERGENCY ROOM SPENDING. I DON'T HAVE ANY BEHAVIORAL HEALTH ADDICTION DATA, SO I DON'T KNOW THE ANSWER. YOU KNOW, I THINK THAT 100% OF OUR PATIENTS WHO ARE IN THAT TOP 1% HAVE SOME FORM OF BEHAVIORAL HEALTH CHALLENGE, SOME CATEGORY, AND IT WON'T SHOW UP IN THE DATA, LIKE YOU WON'T FINE IT IN THE CODES FOR A LOT OF THE FOLKS, WE ARE NOT SENSITIVE TO THE STUFF IN THE MEDICAL SYSTEM, WET DON'T KNOW HOW TO PICK IT UP, WE TRY TO IGNORE IT. I THINK WHAT THIS CALLS OUT IS THERE IS SO MUCH RESEARCH, THE HERSA FOLKS, THE NIH FOLKS, WE ARE NOT FUNDING STUDIES IN THE RIGHT WAY, RIGHT NOW WE TALK ABOUT POPULATION HEALTH AS A FIELD, IT DOESN'T EXIST. THE FIELD OF POPULATION HEALTH HAS ALL THESE WORDS THAT DON'T MEAN ANYTHING AND THAT'S THE DEFINITION OF A FIELD THAT DOESN'T YET EXIST. SO POPULATION HEALTH IS A FIELD THAT INVOLVES BUSINESS THINKING, SYSTEM ENGINEERING, SOCIOLOGIST, AND IT REALLY HARD TO FIGURE ALL THE STUFF OUT. I THINK IT'S DELIVERING BETTER CARE AT LOWER COST EVERY DAY FOR EVERY ONE AND PRIORITIZING THINGS THAT HAVE A DOUBLE BOTTOM LINE WHERE YOU REDUCE COST AND IMPROVE QUALITY BUT WE ARE FAR AWAY FROM HAVING A FIELD OF THAT. THERE ARE A NUMBER OF RANDOMIZED TRIALS WHICH IS THE GOLD STANDARDS IN POPULATION HEALTH WHICH IS VERY LOW. THERE ARE FOUNDATIONAL QUESTIONS WHICH WE HAVE NO IDEA OF. WHAT ARE THE RIGHT SEGMENTS, HOW DO WE FIGURE OUT HOW TO BUILD A HIGH RESTRUCTURED INTERVENTION WITH ROLES FOR EACH SEGMENT, THAT'S THE TASK FOR THE NEXT 20 YEARS. I'LL GIVE YOU AN ACT TEAM IS FOCUSED FACT TORT. YOUR HUD HOUSING ARE FOCUSED FACTORY. NURSE FAMILY PARTNERSHIP IS FOCUSED FACTORY, THEY ARE FOCUSED DELIVERING SERVICES TO A SPECIFIC NICHE IN THE SYSTEM. MANY OF YOU WANT TO RUN OUT OF THE ROOM. THINS IS A GREAT PLACE TO STOP. THANK YOU. [APPLAUSE] >> THANK YOU SO MUCH. THAT'S RIGHT! THAT'S RIGHT! DR. BRENNER, YOU DID NOT DISAPPOINT. I WANT TO THANK EVERY ONE IN HUD FIELD OFFICES THAT ORGANIZED TO BE ABLE TO WATCH THE TELE CAST. THIS IS AA CONVERSATION AT THE VERY BEGINNING AND ONE THAT IS SO RELIANT ON WE AT HUD LEARNING THE LANGUAGE AND THE WAY THE DOLLARS WORK IN THE HEALTHCARE CENTER AND HAVING THAT CONVERSATION WITH YOU, OUR FRIEND AT HHS AND HAVING IT TOGETHER WITH THE OFFICE OF MANAGEMENT AND BUDGET AND THE FOLKS UP ON THE HILL. WE ARE LOOKING FORWARD TO THE CONVERSATION AS WE MOVE FORWARD. THANK YOU FOR COMING TODAY.

Contents

Early life

Josephine Moore
Josephine Moore

John L. Brenner was born in Wayne Township, Montgomery County, Ohio, the son of Jacob S. Brenner and Sarah Ann Matthews. His parents left Virginia because of a dislike of slavery and settled in Ohio; Jacob was a miller and farmer. John Brenner worked on his father's farm in the summer and attended the local public schools in the winter. He finished his education at the Springfield (Ohio) Academy.

John Brenner married Josephine Moore and farmed in Wayne township until 1862. He then became interested in the nursery business which he pursued very successfully until 1872. In 1866, he moved to Dayton, Ohio, then emerging as a center of tobacco agriculture in Ohio, where he became a merchant in leaf tobacco.

Career

John L. Brenner was elected a member of the City of Dayton board of police commissioners, serving from 1885 to 1887. In 1896, Brenner was elected as a Democrat to the Fifty-fifth Congress and re-elected to another term in the Fifty-sixth Congress. Ohio's third district was at the time evenly divided between the two parties, and Mr. Brenner's plurality at each election was barely 100 votes. Brenner was an unsuccessful candidate for renomination in 1900.

Later life and death

After his congressional service, John Lewis Brenner returned to Dayton and resumed his former occupation as a dealer in leaf tobacco. He died in Dayton and was interred in Woodland Cemetery, Dayton, Ohio.

Sources

  • United States Congress. "John Lewis Brenner (id: B000801)". Biographical Directory of the United States Congress.
  • Taylor, William A. Ohio in Congress from 1803 to 1901. Columbus, Ohio: The XX Century Publishing Company, 1900.
  • History of Dayton, Ohio. Dayton, Ohio: United Brethren Publishing House, 1889, 753 pgs.
U.S. House of Representatives
Preceded by
Paul J. Sorg
Member of the U.S. House of Representatives
from Ohio's 3rd congressional district

1897–1901
Succeeded by
Robert M. Nevin
This page was last edited on 19 September 2019, at 03:33
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