The Camden Trial: Where Do We Go from Here?

By Neil A. Solomon, MD

It felt a little deflating to the Social Determinants movement when the New England Journal recently published the negative results of the Camden Coalition intervention. And yet we already know that ignoring social determinants with the high-need, high-cost population is ineffective. The imperative now is to use the lessons of the failed trial to determine what else is needed to help the most vulnerable patients stay healthy and at home.

The Camden trial found that a robust, but essentially social-only intervention did not reduce hospital readmissions compared to a randomized control group. What explains this unexpected finding? Treatment of the underlying medical conditions that precipitate admissions were not actively addressed in the program.

People are admitted to the hospital for medical diagnoses like pneumonia, heart attacks and asthma exacerbations. When medical conditions are not well managed—such as failing to receive appropriate medications or patients unable to practice effective self-management skills—they are much more likely to need hospital admission to stabilize and treat their exacerbations. Perhaps the “aha” from the Camden trial is that even robust outpatient programs that lack concerted attention to medical care and self-management skills are inadequate to sufficiently improve health so as to reduce hospital admissions.

Of course, we also know that the other side of that coin is true. For high-need high-cost patients, an exclusively medical intervention that lacks attention to the social needs of patients will also fail. The most robust medical management of diabetes, for example, can be undermined by the profound food insecurity of an indigent diabetic. It now seems evident that a sustainable solution to maintaining the highest level of health for the most vulnerable population must address both medical and social needs, and do it in an integrated way.

Easier said than done! How often do physician offices have robust social services built into their practices? How often can Meals-on-Wheels staffers directly call a primary care provider to brainstorm nutritional support for a heart failure patient? These types of integration and collaboration are today very rare, but need to become the norm if we are to improve health outcomes while reducing the costs of caring for this population.

Future attempts to go beyond the Camden model must consider the problem from this joint service perspective. MedZed, an organization that I co-founded, is pioneering one such approach. MedZed is a mobile primary care medical group that uses technology to link in services including social, behavioral, pastoral, and specialty medical care. I plan to explore this model of integrating medical and social services in a future blog.