Camden Coalition President and CEO Kathleen Noonan opened Putting Care at the Center 2024 with a reflection on ecosystems of care, a concept that we introduced in the 2018 Blueprint for Complex Care and have built on ever since.

“Partnerships are only the first step. Self-sustaining ecosystems of care aren’t just a collection of partnerships.”

And what does an ecosystem need to be robust and self-sustaining? The Camden Coalition answered that at this year’s conference with the launch of the Ecosystem Assessment Tool, a quality improvement framework for measuring the strength of a community’s ecosystem of care. An interactive chart in one of the conference hallways allowed attendees to explore the tool’s six domains and identify where they were doing the most work and where they needed the most help.

In workshops, town hall sessions, and in the conference’s collaborative Beehive space, presenters shared how they were strengthening their communities’ ecosystems of care across the US and even in Canada.

2024 marked our ninth annual Putting Care at the Center conference, hosted annually by the Camden Coalition’s National Center for Complex Health and Social Needs as a gathering place for the complex care field. This year’s conference was held in Pittsburgh, PA, from October 16-18, and was co-hosted with UPMC Health Plan.

Governance models and backbone organizations

As states increasingly use Medicaid funding to pay for health-related social needs, many in the complex care field worry that the community-based organizations (CBOs) that have been providing these services for decades could be edged out by larger non-profits or for-profit startups. Despite the CBOs’ vital community trust and knowledge, some are poorly positioned to take advantage of the federal funding flooding into states as they do not have the infrastructure and administrative know-how to contract with health systems, bill Medicaid, and set up HIPAA-compliant data systems.

In a Wednesday afternoon fireside chat with Kathleen Noonan, PA Secretary of Human Services Valerie Arkoosh recognized the need for her agency to work collaboratively with CBOs. “At the end of the day,” she said, “a person that is seeking help is going to go to someone they trust.”

One model that has shown promise in its capacity to ensure equity is that of the hub or backbone organization that can act as an intermediary between state health agencies, Medicaid payers, health systems, and CBOs. Hubs can provide regional services like billing and compliance for CBOs, data sharing, convening, training, community feedback, and more.

In a plenary on Wednesday, conference attendees heard from leaders of three different hub models: the Regional Health Hub model in New Jersey, Accountable Communities of Health in Washington State, and Healthy Opportunities Pilots in North Carolina.

Sarah Rideout, Healthy Opportunities Pilot Program Director for Community Care of Lower Cape Fear, said that when her staff run into problems, she tells them that means they’re doing something right. “We are here to hit the bumps,” she said. “That’s why we’re here as a network lead. We’re here to figure out what works, what doesn’t work, pivot, evolve, and make it better.”

All three leaders were clear that they are not there to replace the work of CBOs on the ground. “The worst thing to do when creating coordinated, whole person care is to create a whole new system alongside the one that already exists,” said John Kim, CEO of HealthierHere. “We want to add value: stability, funding, and support.”

Organizing against structural violence

In a fiery keynote address on Thursday morning, Father Paul Abernathy, CEO of the Neighborhood Resilience Project in Pittsburgh, reminded attendees that we make moral judgments about disadvantaged communities when we don’t understand the role structural violence plays in dismantling their ecosystems of care. And, he noted, this violence doesn’t happen by accident.

“What extraordinary effort it took to draw those red lines,” he said, reflecting on the historical practice of redlining and its continuing impact on health inequity across the US today. “The determination and the resolve to enact structural violence on people is nothing short of remarkable.”

Countering those forces of structural violence will take community organizing that aims beyond a single political objective and toward the greater goal of building resilient ecosystems of care.

“We must not just be allies to one another; we must be family to one another,” he said.

During a dedicated time for site visits on Thursday afternoon, conference attendees had the opportunity to visit one of ten examples of community organizations and cultural institutions in Pittsburgh, including Father Abernathy’s Neighborhood Resilience Project.

The group visiting the Neighborhood Resilience Project saw his vision of community organizing against structural violence in action, including supporting residents as leaders in setting and achieving goals for each block of Pittsburgh’s Hill District, and offering a holistic set of resources including food, mental health support, education, healthcare, and trauma response.

During the conference’s story share session Thursday morning, facilitator Luis Ortega, Founder and Director of Storytellers for Change, reflected, “In the face of systems that would fragment us, one of the most radical things we can do is hold onto the wholeness of each one of us.”

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Embracing the whole person

The conference closed on Friday with a plenary session featuring four leaders of the national INSPIRE project that aims to build a national strategy for authentic community engagement in healthcare.

What would it take to meaningfully share power with healthcare consumers? For Burt Pusch, who manages Member-Centric Innovation and Strategy at Commonwealth Care Alliance, the first steps are easy: after an appointment, ask for feedback. Often, he said, providers are “addressing a diagnosis, not a human being.” To provide better care, “you need to get into the shoes of the human being that you’re serving.”

This sentiment was echoed by the people with lived experience of complex needs who presented on panels and workshops throughout the conference.

During “Social needs in healthcare: Turning evidence into practice,” a pre-conference symposium co-hosted by the Camden Coalition, UPMC Health Plan, and the Better Care Playbook, an initiative of the Center for Health Care Strategies, panelist and National Consumer Scholar Pamela Corcoran said that she wants her care team to get to know her as an individual and join her in advocacy. “I’m not just a billing code that leads to financial solvency for an organization.”

And during the story share, Jenn Oakley, National Consumer Scholar and Case Manager at Rising Sun Opportunity, said: “This work matters because I’ve been through this experience myself. My clients are not just numbers, they are people.”

Stories themselves are so important, Luis Ortega reminded us, because “to be a human being is to be a storyteller… We need stories that facilitate connection because we, as human beings, were built to connect.”

Thoughtful uses of data

Though stories and data are sometimes framed in opposition, they are two sides of the same coin. Just as much as it is about sharing stories, Putting Care at the Center is about wrestling with how we use data ethically and transparently to improve care.

“Which concepts you measure and how you prioritize them are important decisions,” said Damon Francis, Medical Director of the Homeless Health Center at Alameda Health System, during a panel at the pre-conference symposium. “Upstream, those get plugged into the software, and they frame the whole system.”

On the Thursday afternoon plenary on building data ecosystems, speaker Manisha Sharma, Senior Director at Promise Health Plans, agreed. “The data is never going to be objective,” she said. “We have to ask the questions: what is missing from the data? Who is analyzing the data?”

Erin Dalton, Director of the Allegheny County Department of Human Services, drew from her experience building and operationalizing an integrated data warehouse in Pittsburgh’s home county of Allegheny, PA. She argued that while data are always biased, they are still better than humans making enormously important decisions without data. Her work has shown that, for instance, women of color in Allegheny County under-report the barriers they are facing, resulting in a lower chance of accessing housing. “Housing supports are a hugely scarce resource,” she said. “When humans make those decisions without tools, they are not providing them to those who need them most.”

“If we’re collecting the data, we have a moral responsibility to use them to improve care,” said Lucy Savitz, Professor at the University of Pittsburgh School Public Health and Senior Advisor at UPMC Health Plan’s Center for High-Value Health Care, on the panel with Damon Francis during the pre-conference symposium.

Building the complex care workforce

The 2024 conference also saw the unveiling of a new set of core competencies for complex care team leaders. Designed to complement the core competencies for frontline providers that we released in 2020, the core competencies for team leaders encompass the skills, knowledge, and attitudes needed by supervisors, managers, and directors of complex care teams.

The Camden Coalition held a workshop on Thursday to take a deeper dive into the core competencies for team leaders. Attendees explored the challenges they faced as team leaders, shared their experiences, and learned about the launch of a new complex care team leaders’ certificate scheduled for fall 2025 that will complement the Complex Care Certificate for frontline staff that is currently offered on the Camden Coalition Learning Center.

Workforce is one of the domains of the Ecosystem Assessment Tool, and the need for better support and training for the complex care field’s unique workforce echoed throughout the conference.

“Navigating an organization as a peer specialist is daunting,” said Family Peer Specialist and National Consumer Scholar Angela James during the story share. “I am the only peer on staff. My education has been sought on my own.”

“If we had half as many resilience experts in our communities as we have trauma experts, our communities would be in a much better place,” Father Abernathy observed in his keynote.

During the INSPIRE plenary, speakers talked about best practices for bringing people with lived experience in as staff members, consultants, or advisors. “What you don’t want to do is bring people into a power imbalance,” said Brandon Wilson, Senior Director of Health Innovation and Public Health and Equity at Community Catalyst. “We [must] make sure that compensation is equitable. That’s a way to honor people’s time, experience, and expertise.”

Systems designed for connection

In reflecting on his journey from hospitalist to complex care provider, plenary speaker and Chief Medical Officer of the Camden Coalition Jubril Oyeyemi noted that “the hospital wasn’t designed to serve complex populations. There’s a discrepancy here — we are failing them, but it’s because the system wasn’t designed to help them.”

“Our health care system’s funding and payment model incentivizes — rewards, even — fragmentation and competition,” Kathleen Noonan said in her welcome address. “Working together for whole person care, good outcomes, and health equity is hard because it requires us to bring together competing players and intentionally work to counter fragmentation.”

At its core, Putting Care at the Center is about the importance of connections and relationships — from the individual level to the community level.

“Trauma is disconnection, and healing can only happen through connection,” said closing speaker Jonathan Weedman, Senior Vice President of Clinical Services at CareOregon.

CareOregon will be co-hosting Putting Care at the Center 2025 next fall in Portland, Oregon. Learn more on our conference page, and sign up for our newsletter to be the first to hear about presentation opportunities and how to register.