Understanding our patients' behavioral health and social needs

Complex care serves individuals who are repeatedly cycling through healthcare, social service, and other systems but who do not derive lasting benefit from those interactions. The Camden Core Model, our signature complex care program, serves people with complex needs in Camden, NJ. To improve the quality of our patients’ care, a clinical psychologist assessed their psychiatric, substance use, and social needs.

We found a wide range of behavioral health and social needs, including high rates of active mental health and substance use diagnoses, physical and emotional trauma, and housing instability. Furthermore, we learned that while most patients had recently seen their primary care provider, very few were currently receiving treatment for their behavioral health diagnoses. These findings underscore the need for policies and incentives that support integrated medical-behavioral healthcare, and which strengthen connections between primary care practices and social service providers.

Cross-Sector Data in Action
Cross-sector collaboration can provide crucial data for programs that address the root causes of poor health. This brief, Cross-Sector Data in Action, highlights ways that…
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Navigating Legal Parameters for Cross-Sector Data Collaboration
Legal and regulatory questions are common among groups working to share cross-sector data. This brief, Navigating Legal Parameters for Cross-Sector Data Collaboration, provides examples of how…
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Building Trust for Cross-Sector Data Collaboration
Cross-sector data sharing relies on strong relationships between organizations. This brief, Building Trust for Cross-Sector Data Collaboration, explores ways to create and strengthen data partnerships.…
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Sample Data Sharing Agreements
Cross-sector data sharing is lauded as an integral part of complex care. Sharing data between multiple sectors—such as behavioral health, medical, criminal justice, housing, and…
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Understanding our patients' behavioral health and social needs
Complex care serves individuals who are repeatedly cycling through healthcare, social service, and other systems but who do not derive lasting benefit from those interactions.…
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Blueprint for Complex Care
Advancing the emerging complex care field to effectively address root causes of poor health cannot be achieved by individual organizations. Doing so requires a…
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