MacArthur Foundation announces 2013 Fellows

[Tanuki]

http://www.macfound.org/fellows/class/2013/
Lots of talent and hard work. This one caught my eye:
"Jeffrey Brenner is a primary care physician creating a health care delivery model to meet the medical and social service needs of the most vulnerable citizens in impoverished communities. Determined to improve the lives of the sickest residents of Camden, New Jersey—one of America’s poorest cities—Brenner constructed a searchable database and geographic mapping of discharge data from all patients at Camden’s hospitals and discovered that a very small number of patients consumed a large share of the overall costs of health care and social supports. To address this issue, Brenner established the Camden Coalition of Healthcare Providers, bringing together doctors in community-based private practices, frontline hospital staff, and social workers across the city to participate in a strategy of comprehensive preventive and primary care. He designed a system that delivers daily information about hospitalizations to the Coalition and members of Care Management Teams. Each team is made up of a registered nurse, one or two licensed practical nurses, a health coach, and a social worker to support and help coordinate care for patients with complex medical, and often social, issues. Brenner has demonstrated that using this model of cooperative care—identifying and visiting high-risk patients, earning their trust, offering access to clinical services, heading off medical complications before they occur, addressing social needs before they become medical problems—can reduce repeated emergency room visits and hospitalizations and lower health care costs. Currently working with ten communities across the country, including Allentown, Pennsylvania; Aurora, Colorado; Kansas City, Missouri; and San Diego, California, on developing sustainable and accountable care systems based on the Camden model, Brenner’s collaborative approach to health care delivery is an important contribution to the national conversation on health care reform. "