The COVID-19 pandemic has hit communities that were already under-served by healthcare, social service, and public institutions the hardest. Before 2020, people with complex health and social needs already had enormous challenges accessing the care they needed, and the pandemic has only underscored how critical access — to screening and preventative care, services, information, and data — is to the health and well-being of communities like ours here in Camden.

Our organization’s role has always been to connect people who fall through the cracks of our current systems to the services, supports, and relationships they need. We have learned over time that doing this effectively requires more than simply connecting patients to services — we must bring the services themselves together into an interconnected ecosystem in order for people to be able to access truly whole-person care.

COVID-19 made access to a functioning ecosystem of care more critical than ever. 

The pandemic is bigger than any one institution, any one organization,” says Victor Murray, Senior Director of Community Engagement and Capacity Building at the Camden Coalition. “We’ve seen that addressing these issues only through the lens of ‘my institution’ or ‘my organization’ is both narrow and ineffective.”

As one of New Jersey’s four Regional Health Hubs, we act as a bridge between the state government and the institutions involved in providing care to Medicaid patients in South Jersey. Throughout the COVID-19 pandemic, that has meant ensuring access to what both community members and other organizations in our ecosystem need: convenient testing and vaccination, and timely and accurate information, education, and data sharing.

Information and data sharing

People with complex health and social needs interact with many different institutions and organizations in their community. Data sharing infrastructure is the backbone of the complex care ecosystem as it gives each of these organizations a fuller picture of the needs and goals of their patients and clients. As COVID-19 spread across our community, the need for timely data sharing was particularly acute. We realized that, as is the case in many under-resourced communities across the country, various stakeholders held different pieces of the data picture and no one was capturing a comprehensive picture of how the pandemic was impacting the region.

Our Camden Coalition Health Information Exchange (HIE) became a critical way for frontline agencies to access the data they needed. Our HIE ensured providers could access lab results, enhanced contact tracers’ ability to identify and engage individuals, flagged vulnerable patients for proactive outreach and vaccine prioritization, and hosted cross-agency and provider workflows to support vulnerable populations.

We also created a centralized clearinghouse of information about service changes due to COVID on our website, called our COVID resource hub As the initial influx of information stabilized, we heard from the COVID vaccine ambassadors on our Community Advisory CommitteeMy Resource Pal, our social service directory for South Jersey.

Fighting misinformation

Fighting misinformation about vaccine safety has been another way we’ve ensured that our community members have access to the accurate information they need. In 2020 we launched a community ambassador program made up of trusted messengers on our Community Advisory Committee who are paid a stipend to share accurate information about the virus and vaccination with their neighbors. They also share any feedback they’re hearing from their neighbors with our staff and a representative of the Camden County Department of Health at weekly meetings. This has helped us work with Camden County to improve local vaccination programs and stay ahead of misinformation. In order to better engage youth and families, in early July we launched a youth ambassador program.

Even before the COVID-19 vaccines were available in Camden, we launched a community vaccine survey in the fall of 2020 to learn about community members’ attitudes towards vaccines — both the COVID-19 vaccines and routine vaccines like the flu shot. We followed that up with a survey for local healthcare providers on their vaccine education practices and whether they felt prepared to address vaccine hesitancy among their patients.

The results of both of these surveys informed a series of trainings for local organizations’ clinical staff members — including nurses, medical assistants, and front desk staff — on addressing vaccine hesitancy. The survey results also helped us to equip our community vaccine ambassadors to talk effectively to their neighbors about the importance of getting vaccinated and to dispel common myths. “Talking to patients about the COVID-19 vaccines” is a guide we created for our local providers. We used a modified version of the guide to train our vaccine ambassadors to confidently address vaccine hesitancy in the community.

In January 2021, our Medical Director Dr. Jubril Oyeyemi started filming a series of short videos addressing common concerns he had been hearing about the COVID-19 vaccines. The three videos in the series were shared widely over social media.

• Addressing COVID-19 vaccine concerns
• Addressing concerns about COVID-19 variant strains
• Addressing concerns about Johnson & Johnson vaccine pause

Ensuring access to testing

Concentrating COVID-19 testing in mass testing sites that are only available by car means that those who are most vulnerable to the virus aren’t able to protect themselves, their loved ones, and their neighbors from infection. One of our biggest priorities has been to ensure that Camden residents can access COVID-19 testing in locations that are easy to get to by car, foot, or public transit, and that are located in existing COVID hotspots. In the fall of 2020 we worked with the Camden County Department of Health and Cooper University Healthcare to launch three local testing sites in areas with low access to the larger mass testing sites, staffed first by Camden County and then by Camden Coalition staff.

Because we know that the virus itself is only one of the challenges our community members have faced during the pandemic, we also embedded social needs screening at the testing sites through our Accountable Health Communities (AHC) initiative. Residents who needed help accessing social services got follow-up help from one of our AHC navigators. As demand for testing lessened, we scaled down to one site at KIPP Cooper Norcross Academy.

Vaccination at the community level

“At the end of the day, the most gratifying marker of success is getting shots in arms,” says Victor.

Once the COVID-19 vaccines became available in Camden, we worked closely with the county and other partners in the region to ensure that those most at-risk of contracting the virus (i.e., Black, Latinx, and low-income individuals, and those with complex health and social needs) were able to access the vaccine. When a FEMA-run mass vaccination site came to Camden in March, we turned to our Camden Coalition Health Information Exchange to ensure that everyone in the city who was eligible for the vaccine at the time, including those who did not have a primary care provider, was added to the list that our partners at a local Federal Qualified Health Center, CAMcare, were using to schedule appointments. Over a third of our staff volunteered to make calls to eligible community members. In under a week, we made 1,400 calls to 1,025 residents and scheduled 232 vaccine appointments.

After the mass vaccination site closed, we took the vaccination effort into the community, co-hosting pop up vaccine events with our local partners. Miguel’s Pharmacy, a local independently owned pharmacy in Camden, had been doing vaccine appointments but knew that they weren’t reaching everyone in the community that way, and were limited by only having one pharmacist able to do vaccinations at a time. They asked us to help them coordinate and staff a series of walk-up vaccine events. Our nurses helped administer the injections, our AHC staff provided social needs screening and referrals, and staff from across the organization helped with paperwork, health education, and handing out incentives like gift cards, food, and ice cream.

Miguel Arriaga, owner of Miguel’s Pharmacy, said that the events have been a huge success. “How successful?” he asks. “Last weekend it was raining and we did 78 shots in four hours: one shot every 10 minutes — despite the rain!”

The Camden Coalition is a major supporter of everything that happens in the community, and a major supporter of our battle against COVID-19,” Miguel says.

Because Miguel’s Pharmacy is so known and trusted in the community, its vaccination program has become a haven for undocumented immigrants who were wary of getting vaccinated at the larger vaccine sites. Gladys Antelo, a nurse at the Camden Coalition, reports that at the events there were long lines of folks who didn’t speak English. “People were just excited and nervous,” she says. “People wanted to be able to visit their families in their home countries without being worried about getting them sick, to go home without worrying about getting their grandparents or loved ones sick. There was a lot of anxiety but a lot of love and happiness. It was palpable, the amount of energy and love that was in that parking lot.”

Through 16 vaccine events thus far, three at Miguel’s Pharmacy and others at local schools, churches, and other community settings, the Camden Coalition has been able to help vaccinate hundreds of people.

Looking ahead

“One of the worst things that could happen is for this pandemic to subside and for people to go back to business as usual,” says Victor. “How do we sustain this community infrastructure? How do we continue to leverage these relationships so that when the next big thing comes, we’re ready? How do we use this infrastructure to have long-term impact on the chronic issues we already see plaguing Black and brown communities?”

The COVID-19 pandemic, along with the pandemic’s economic and social impact, has had a major impact on a community already traumatized by poverty, racism, and disinvestment. This particular event has been marked by the trauma of isolation and fragmentation — lack of access to the services, connections, and relationships that people need most.

We believe that trauma-informed systems are as important as trauma-informed care. Post-COVID, we must make sure that our systems are so resilient and interconnected that even in a global crisis, those in the most complex and difficult situations are able to access what they need.

Looking for a place where you can learn and share about building strong ecosystems of care post-COVID? Join us at Putting Care at the Center 2021 This year’s annual conference on complex care will be organized around the theme of Trust, trauma, and healing in our communities. Our community vaccine ambassadors will be joining complex care leaders from across the country to present lessons learned from their work.