The Camden Coalition’s vision to improve the wellbeing of individuals with complex health and social needs is only possible through collaboration with individuals and organizations throughout the region, state, and nation. Locally, we regularly convene the Community Advisory Council, care providers in Camden (via the Care Management Meeting), and the Camden Coalition Accountable Care Organization (ACO) partners to foster the exchange of ideas and best practices to improve complex care delivery in Camden. But until recently, these diverse stakeholder groups have not formally convened at the same table to work through a common issue.

Now that’s changed, with the first convening of the Complex Care Collaborators group on April 25.

The Camden Coalition staff who convene the three groups — Dayna Fondell (Camden Coalition ACO), Laura Buckley (Care Management Meeting), and Whitney Buchmann (Community Advisory Council) — recognized the growing need to jointly convene the stakeholders. “The groups were all experiencing an opportunity to redefine the purpose of their gatherings,” said Whitney. “We saw this as a moment to respond to some of the emerging themes that have been raised across multiple settings, and to better align across our local stakeholders — the healthcare consumers involved with the Community Advisory Council, and the clinical and social service providers who participate in the Care Management Meeting and ACO Dinner.”

To narrow down on a focus area that the groups can jointly address, the staff members presented to the groups the top themes that had emerged across the three settings: food insecurity and access, behavioral health transitions, and care coordination and data sharing. They also facilitated discussions and prioritization exercises to co-identify a shared pain point, using a journey-mapping approach developed by the Commonwealth Care Alliance and The Center to Advance Consumer Partnership to encourage joint problem-solving and grassroots innovation. After extensive conversations, the groups ultimately decided that they could most effectively address the issue of food insecurity and access together.

Last month, 34 clinical and social service providers, and healthcare consumers convened at the Camden Coalition office to seek a better understanding of the food access challenges in Camden. They created journey maps of the food access experience, identified common pain points, and shared their experiences. Out of the three topics that surfaced to the top of the discussions — transportation barriers, food that meets the health needs of consumers, and knowing the right resource — the participants voted to prioritize “knowing the right resource” as the specific problem to solve together.

“The conversations between community members, clinicians, and social service providers highlighted the fact that good resources exist, but both providers and community members feel frustrated that they don’t always have the information to make the community referral successful,” said Dayna. “For example, one community member talked about her experience of being referred to a site that was ‘first come first served’. She showed up during the hours of operation, but because she didn’t know to go earlier in the day, the pantry was out of the foods she needed most.”

We need to find a way so people can be better informed on what’s happening and what’s available.

— Complex Care Collaborators participant Reverend Gregory Stratton

“I was especially surprised to know that there are so many people who don’t know that certain things are available in Camden,” said Complex Care Collaborators participant Reverend Gregory Stratton. “Within my building where I live, we get information passed around very well by word of mouth. There’s a lot of people in the city who just don’t get the information they need from churches or other organizations they’re a part of. We need to find a way so people can be better informed on what’s happening and what’s available.”

Gregory Mayers, Virtua’s Manager for Community Health Engagement who is also participating in the Complex Care Collaborators group, said that Virtua knows firsthand that collaboration is key to addressing health-related social needs, like food access. “Food insecurity is a complex problem with a range of contributors, many of which overlap, such as housing, health, and employment. One-size-fits-all and top-down approaches don’t work, which is why it’s critical to convene both consumers and providers to truly understand the root causes and work towards holistic, culturally-competent, and effective care plans.”

This summer, the Camden Coalition will work closely with the stakeholder groups separately to better understand the top pain point and how they would propose to resolve it, and analyze potential solutions. The Camden Complex Care Collaborators group will next convene in September to discuss solution ideas and produce recommendations. Following the second convening, an implementation plan will be created in the fall, with the goal of rolling out a joint effort early next year.

“The Complex Care Collaborators group is unique because it can remove the power dynamic of a clinical or social service visit,” said Gregory Mayers. “This helps to build trust between community members and providers that allow for honest conversations. Convening diverse stakeholders also bridges clinical and social providers, which can break down silos and connect wraparound services to ‘close the loop’ of screening, referring, and evaluating outcomes. Food access and insecurity can’t be solved alone. It will take a comprehensive approach including community members, healthcare professionals, and social service providers.”

If you or your organization is interested in investing in the project, please contact Matthew Kalamar, Associate Director of Grants and Development, at [email protected].

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