Phase 4 of the Camden Core Model: Creating an Ecosystem for Complex Care (2018-2019)

While discussions about the social determinants of health are featuring more prominently in the nation’s current health policy conversation, many organizations, like the Camden Coalition, have been working for years to understand and address this intersection. In the spirit of reflection and continuous learning, we thought it was timely to share the story of the Camden Coalition’s 15-plus years developing a care model that is centered around both health and social complexity.

This piece, “Phase 4 of the Camden Core Model: Creating an ecosystem for complex care (2018-2019),” is the fourth in a four-part series that describes the phases of the Camden Core Model as we addressed challenges and tested new solutions. Read all four sections together in this brief.

Armed with a deep understanding of the extent of our patients’ needs and the significant limitations of our current systems to address them, we have turned our attention to creating ecosystems for complex care, both in the Camden region and nationally.

This has meant changes to our Care Team, a growing focus on regional and national partnerships, and an expanded dialogue about the inability of our current systems and structures to address the needs that we observe in Camden and around the country.


Starting a Medical-Legal Partnership

After several years of planning, we were able to launch a Medical-Legal Partnership with Rutgers Law School in 2018 to support our Care Teams and their clients. A consulting attorney joined the Coalition’s complex care team alongside nurses, social workers, and community health workers to resolve legal needs that can undermine patients’ health and well-being. To date, our consulting attorney has worked on legal matters for 41 patients, obtaining both reductions in fines and access to benefits. At this point, we cannot imagine addressing our patients’ needs without access to an attorney working alongside our Care Team. 

Establishing Regional Health Hubs to better serve our patients

Over the course of our model’s evolution, other care management programs have also emerged in Camden and the surrounding region. We are also now thinking about how our program may need to evolve even further to meet patients’ needs — and about the realities of a healthcare system that has not changed as much as we hoped and a social service system whose investments have not kept pace with the population’s needs. Since 2007, we have seen the health care field respond to a call for expanded care management and home visiting models, but very little of it is done collaboratively. In Camden, we continue to hold monthly care management meetings which bring together 40 to 50 people each month who are navigating patients with chronic health issues, and other social needs.  These meetings are vital to our region’s ability to share resources, and collaborate around patient needs. And yet, we feel the field needs a more sophisticated approach to care management that connects high-touch, high-stakes navigation, such as navigation from the emergency department for a patient with medical and social complexity, with longer term navigation support that crosses sectors.

We need a sophisticated approach to care management that connects high-touch navigation with longer-term cross-sector support.

— Kathleen Noonan and Kelly Craig

To further this approach, the Coalition has worked with state-level partners to establish the organization as one of four Regional Health Hubs in New Jersey to leverage our care management experience to serve individuals in the broader Camden region through navigation, convening, and data sharing. Over the past 12 years, our social sector partners have not been able to make the same investments in data and infrastructure that has been possible in healthcare. Through our Regional Health Hub, we hope to make the Camden Coalition HIE more widely available, and learn even more about our care management approach’s impact on patients.

Strengthening the field of complex care

Through our National Center, we continue to highlight the fact that complex care works at the systemic level by creating ecosystems — local networks of organizations that collaborate to serve individuals with complex health and social needs. Through these efforts, complex care needs to address the root causes of poor health that defy existing boundaries among sectors, fields, and professions. The most expensive and challenging populations for the current healthcare system will remain underserved until there is a unified effort — rather than small, incremental steps — to improve care for people with complex health and social needs, and question the limitations of the existing models of care. Complex care programs may be housed in many settings, ranging from health care clinics and health plans to community-based organizations and social service agencies. Because of the broad set of stakeholders providing complex care, there is risk of further fragmentation of services, which makes ecosystem development an even more critical goal. Our focus in Camden is on ensuring that we build systems that propel us toward this goal.

Looking ahead

While we are continuing our core case management with individuals with both medical and social complexity, we are also looking for new ways to holistically address complex needs. We know that our original idea that we could navigate and piece together services that require a patient to move from provider to provider, each with their own eligibility requirements and service gaps, is not the way forward. In other words, short-term help navigating back to healthcare is not the answer. It is one part of the puzzle, but health systems cannot solve these problems on their own and may not even be the best “home” for many patients with certain types of medical and social complexity. Instead, systems and models of care have to be built around patients’ complex needs. The Camden Coalition is testing this theory in a variety of ways. For example, we are embarking on a pilot to more closely link social services to our HIE and, by harnessing the data-sharing power of this effort, also institute joint care planning activities alongside providers to serve our patients even better. 

Short-term help navigating back to healthcare is not the answer. Systems and models of care must be built around patients’ complex needs.

— Kathleen Noonan and Kelly Craig

The Camden Core Model has gone through many phases. As we considered our successes and challenges, we made changes to our staffing, engagement practices, data infrastructure, and more. This is the hallmark of any learning organization — the willingness and ability to continuously iterate on a process in order to make it better. We look forward to sharing more of this story with the field as we continue to refine how we serve our patients.

Read the story in full on Medium

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