Using data to identify and engage patients with complex health and social needs is the foundation of our work.
This data-driven approach, known as healthcare hotspotting, allows us to identify and engage patients with medical complexity and poor healthcare outcomes. From our early days combing through hospital claims data to our current Camden Coalition Health Information Exchange, which links healthcare and other records across South Jersey, we connect data across institutions to better identify and serve individuals with unmet needs.
Sharing data is an important element of cross-sector collaboration. We use shared data to:
- Conduct healthcare hotspotting, through which we identify and engage patients with patterns of high hospital and other system use in real time
- Enroll patients in our care interventions
- Build lasting partnerships between the organizations and sectors that are part of the lives of people with complex needs
- Design programs that address the needs of vulnerable populations
- Advocate for improvements to the delivery of medical, behavioral health, and social services
- Conduct actionable research that informs policy and practice.