Published On: January 2017 in Kaiser Health News. Read the story here. This KHN story also ran on PBS NewsHour.

HOUSTON — Donning a protective gown, rubber gloves and a face mask, Dayna Gurley looks like she's heading into surgery. But Gurley is a medical social worker charged with figuring out why her client, a man who uses more health care services than almost anyone else in Houston, has been in three different hospitals in the last month.

The patient, who asked not to be identified, has chronic massive ulcers, AIDS and auditory hallucinations. He rents a cot in another person's home but is more often homeless, with no family to help him.

Published On: January 2017 in PBS NewsHour. Read the story here.

Health care "super-utilizers" make up just 5 percent of the U.S. population but they account for 50 percent of health care spending. As health care costs continue to rise, providers are trying to figure out how to find these patients and get to the root of their problems. But the looming repeal of the Affordable Care Act may disrupt those efforts.

Published On: December 2016 in Episcopal Health Foundation. Read the story here.

He was sitting in his old wheelchair with his phone in his hand. He was grey, had difficulty breathing and was very confused. We immediately called 911.

Timmy was on the outside of the health system looking in. And it almost cost him his life.

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.