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Improving care for people with complex needs

Woman smiling at a podium onstage at a Putting Care at the Center conference
Program participant hugs care team member as both smile on a couch
Camden Coalition staff member explaining something while sitting at a conference table

Our health and social systems will work for everyone when they work for those they are failing the most.

Currently, our healthcare and social systems are set up to treat individual needs in isolation. By piloting and demonstrating care models that work for those with the most complex needs, we work to transform and connect fragmented systems — in Camden, across New Jersey, and around the country — into equitable ecosystems of care.

Because when providers, organizations, and sectors work together, every individual — regardless of their needs — can receive person-centered care.

About the Camden Coalition

Housing First participant hugs community health worker in his new apartment

Advancing equitable ecosystems of care

No single organization can meet all of its community members’ needs. For truly coordinated whole-person care, organizations, sectors, fields, and professions must work together. We support South Jersey’s ecosystem of care as a designated Regional Health Hub, and work with communities across the country to build and strengthen their own care ecosystems.

Community event checking blood pressure

Demonstrating what works

From new care management pilots to system redesign to national learning collaboratives, we demonstrate what works and what doesn’t to improve care, build an evidence base for the complex care field, and share best practices through teaching and training.

Learn more about our work

New at the Camden Coalition

Building a longitudinal community supports model
nurse checking heartbeat

Building a longitudinal community supports model

What are new 1115 waivers that allow Medicaid to address health-related social needs still missing? For people with the most complex needs, point-in-time community services and time-limited care management aren’t enough. Long-term, community-based support — like our Housing First program — need to be funded and prioritized. Read more in a Health Affairs Forefront commentary from our CEO Kathleen Noonan and Penn Leonard Davis Institute Senior Fellow Mary Naylor.

Explore the Ecosystem Assessment Tool
Each domain has specific attributes that form the framework for the Ecosystem Assessment Tool. Workforce domain has the attributes teaming and collaboration, training in core competencies, and community representation. Services domain has the attributes whole-person care management, screening and referrals, performance monitoring, and best practices and innovation. Data & measurement domain has the attributes community data sharing, participant engagement in data sharing, analytics and workflows, and shared quality metrics. Leadership & governance domain has the attributes coordination across stakeholders, breadth of network, and equitable leadership and decision making. Payment & funding domain has the attributes resources for whole person care and aligned incentives on value. Finally, the consumer participation domain has the attributes authentic consumer engagement, consumer-informed decision making, and sustainable resources dedicated to consumer engagement.

Explore the Ecosystem Assessment Tool

How can we measure the impact of our work on a community’s ecosystems of care? We developed the Ecosystem Assessment Tool as a continuous quality improvement framework that ecosystem partners can use to track their collective progress.

New resources for better care

Putting Care at the Center attendees holding the COACH fact sheet
Camden Coalition staff laugh in front of white board covered with post-its
Adding post-it to poster labeled "complex care ecosystem"

See all our resources