By Dawn Wiest and Laura Buckley

Through our signature care management program, the Camden Core Model, our care team serves people with complex health and social needs in the Camden area. Our patients often repeatedly cycle through multiple healthcare, social service, and other systems but do not see lasting benefit from those interactions.

Patients enrolled in our intervention are served by an interdisciplinary care team of nurses, social workers, and community health workers. Between 2014 and 2017, patients who our care team suspected had behavioral needs, or who reported behavioral health needs themselves, were referred to Karen Rentas, PhD, a clinical psychologist. Dr. Rentas worked in consultation with our care team to provide comprehensive behavioral health assessments for these patients, and asked them about their housing situation and exposure to emotional and physical trauma. Although the assessments were conducted primarily for care coordination purposes, we analyzed the data collected by Dr. Rentas and published our results in BMC Health Services Research on February 8.

Key findings about the behavioral health and social needs of our patients are:

  • Of the 195 patients assessed, 185 were diagnosed by Dr. Rentas with an active psychiatric or substance use disorder. Forty-three percent of patients had a mental health and active substance use comorbidity. Major depressive disorder, bipolar disorder, and post-traumatic stress disorder were the most prevalent psychiatric diagnoses. Alcohol, cocaine, and/or opioids were the most common substances used among patients with an active substance use disorder.
  • Despite nearly all patients reporting they had a primary care provider, and 66% indicating they had seen their primary care provider within three months of their most recent hospitalization, very few were in treatment for their psychiatric or substance use disorder at time of assessment. Among patients who were diagnosed by Dr. Rentas with a psychiatric disorder, 17% were receiving mental health treatment, and only 10% of patients diagnosed with an active substance disorder were in treatment.
  • Trauma exposure across the lifespan was common among these patients, with 61% reporting trauma in childhood, adulthood, or both.
  • At time of assessment, 35% of patients were either homeless, staying with friends or family due to financial reasons, living in a shelter or rooming house, or had recently received an eviction notice.

We anticipated finding a high prevalence of behavioral health and social needs among the patients who were assessed. What was most surprising to us was learning that while nearly all of the patients had a primary care provider, and two out of three patients had a recent primary care visit, only a fraction of those with active behavioral health needs were receiving treatment to address those needs.

Our findings underscore the need for greater knowledge about the obstacles to providing integrated medical and behavioral health care in primary care settings, and the need for policies and incentives to better support providers in their efforts to address the behavioral health needs of their patients. Moreover, our findings about the prevalence of trauma exposure and housing instability highlight the need for stronger connections between primary care and social services.

The Camden Coalition is bridging this crucial gap through Accountable Health Communities, a five-year national model of the Center for Medicare and Medicaid Innovation. We are partnering with clinical and social service providers across three South Jersey counties to screen Medicare and Medicaid beneficiaries for a range of health-related social needs and provide them with health and social service navigation. By building strong partnerships across medical, behavioral health, and social service sectors, we can systematically address interrelated health and social needs and provide whole person care that truly addresses the needs of patients.

Read our study in BMC Health Services Research.

Read our quality improvement brief outlining our evaluation results.

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