Care Management Initiatives

Compassionate care to reduce unnecessary hospital utilization

Our multidisciplinary Care Management Initiatives teams work in the community every day, making a difference to some of Camden’s most vulnerable citizens.

We identify patients with frequent hospital admissions using real-time data from the Camden Health Information Exchange. Staff members meet patients at the hospital bedside to offer them the opportunity to participate in our care coordination services. Enrolled patients work with a community-based team of nurses, social workers, community health workers, and health coaches for about 90 days.

Our care teams empower patients to address not only medical issues but also behavioral and social barriers to wellness. The team links patients to resources throughout the community, including primary care, transportation, housing, and other wrap-around services. Team members accompany patients to their appointments while helping patients gain the skills and support they need to avoid readmissions.

The Coalition is currently testing the effectiveness of the high-utilizer intervention in a randomized controlled trial conducted by MIT’s Abdul Latif Jameel Poverty Action Lab (J-PAL).

The Care Management Initiatives are funded by  The Nicholson Foundation and the Bristol Myers Squibb Foundation as well as a grant from the Center for Medicare and Medicaid Innovations (CMMI)

Read our study about our patients’ behavioral health and social needs in BMC Health Services Research.

Read our blog post about our findings published in BMC Health Services Research.

Read our quality improvement brief outlining our evaluation results.

Read about how our intervention addresses addiction.