We sat down with Camden Coalition’s Chief Medical Officer, Dr. Jubril Oyeyemi, and Lisa Mojica, MSW, Program Manager for Clinical Redesign Initiatives, to hear about how we develop and use shared care plans with our local partners to align care across systems and reduce fragmentation in South Jersey as part of our program Pledge to Connect (Pledge). Dr. Oyeyemi and Lisa spoke with us about the improvements they’ve seen in patient outcomes since introducing shared care plans, how four regional health systems are working together to maximize the impact of their collaborations, and how further technological solutions are needed to make it easier for clinicians and other providers to access shared care plans through electronic health records.

Nearly twenty-five years ago, the Camden Coalition started as a monthly breakfast meeting, bringing together local providers determined to improve care for Camden’s highest-need residents. Together, the group identified that a small number of individuals accounted for a disproportionate number of emergency department visits and healthcare costs.  This fragmentation represents both a major gap in our current healthcare landscape and a cost inefficiency for Medicaid, Medicare, and commercial payers. This also frustrates ED clinicians and other medical workers who may or may not recognize these patients are receiving care across health systems and other outpatient clinics, and further cannot tell – even with the same electronic health record system vendor – who is point on overall care management.

Today, the Camden Coalition hosts monthly regional case conference meetings for Camden-area health systems and community partners to gather and coordinate care for their shared — and our region’s highest-need —patients. A central activity of the cross-sector case conference meetings is creating shared care plans that designate a primary care management contact responsible for understanding and coordinating care across systems.

We talked Dr. Oyeyemi and Lisa about this work.

How do shared care plans help improve care for complex care patients?

Lisa:Care planning isn’t anything new, but it’s traditionally just done with care teams working directly with the patient. At our monthly regional case conferences, when we do shared care planning, we have one representative from each of the local, regional hospitals in attendance. In addition, we also have the behavioral health navigation teams from Cooper University Health Care and our Certified Community Behavioral Health Clinic partner, Oaks Integrated Care. It’s unique to have everyone in the room working together as we’re discussing a patient, and it helps us see the bigger picture of where there are barriers and challenges and what other agencies or providers should be at the table. It’s also valuable to have the opportunity to proactively convene every month because, typically, this sort of cross-sector collaboration around a patient — if it happens at all— is through one-off case conference meetings called in response to a crisis.

Dr. Oyeyemi: In addition to establishing a primary contact, care plans are filled with all sorts of learnings that, if you were reading the doctor’s note, wouldn’t necessarily be in there. It gets into such detailed things like, “This is how they want to be communicated with” or, “They like to be addressed this way.” It’s even down to things like, “If this person is going through this, here is a contact person that can often de-escalate it, and this is who this person has the best relationship with in the community. Reach out to them.”

[This information] is vital to providing care to this person — that way you don’t make the same mistakes that we’ve learned from before because, with our complex folks, when you make that mistake, you’ve lost trust. And the thing is, providers and the care team at a new hospital can always deviate from the care plan, but [the care plan] helps them at least be aware of baseline and historical information.

How have you seen shared care plans improve patient outcomes?

Lisa: We have seen major shifts in ED visits since we started utilizing shared care plans. We have one individual who was going to local EDs about 45 times a month when their case was brought to our care planning meeting. We could tell that the patient had a lot of unmet needs—they needed an ID, housing, food, and access to specialized care. We hashed out the next steps, discussing what the plan would be if the patient went to each hospital and designating a primary contact within each health system.

At the time, this patient was primarily going to Cooper, but then one day, they went to Jefferson [Health]. Jefferson recognized their name and reached out to us to confirm that this was the patient discussed in the shared care plan meeting. After confirmation, the team used the Camden Health Information Exchange (HIE) to review their care plan and find out who the appropriate contact for their care was. Since the care plan essentially provided a brief description of what the patient was already connected to, Jefferson’s team was able to connect them back to their long-term supports like their case manager, group home, and other services they were referred to through our program Pledge, which connects ED patients with outpatient treatment. Since then, the patient has been able to get his needs met outside of the ED, and now he only goes every few months for acute medical issues. After working with his case manager and taking the necessary steps to reach his goals, he was connected to permanent housing, ending his 20 years of chronic homelessness.

By establishing clear communication pathways, designated points of contact, and agreed-upon next steps, the shared care plan enables real-time coordination among health systems and community-based providers. This approach improves continuity of care for individuals with complex behavioral health needs, enhances the patient experience, and supports more proactive interventions that can reduce avoidable emergency department utilization and hospital admissions. Ultimately, this work fosters a culture of collaboration and shared accountability, leading to better outcomes for patients and a more integrated system of care.

How do technological gaps limit the impact of shared care plans?

Dr. Oyeyemi: The care plans that are created [in regional case conferences] are shared, meaning the goal [of the care plan] is to share it across everyone who’s touching this patient. The issue we’re seeing is that even though some of the health system partners have the same EMR [electronic medical record] system, Epic, they don’t all have real-time access to that shared care plan.

With our complex patients, they’re coming into the ER multiple times a day sometimes. Right now, we create a care plan together at the regional case conference, but then each partner leaves and puts the care plan in their own system. Let’s say someone has gone to Virtua Health 20 times in a month, and each time their providers update their care plan. When the person walks into the ED at Cooper, the record of those 20 visits is lost. This is vital information — about medications, what worked for this person, and what didn’t — that has to wait until our next monthly regional case conference.

How are we working to address this?

Dr. Oyeyemi: One of our hospital partners, Virtua [Health], has hired a program manager to work with Epic to fix this. The idea is that the EMRs should all “speak to” each other so that no matter which healthcare system the patient is walking into, their providers can see the most up-to-date version of their care plan. They’re also going to add a flag so that when you open a patient’s file, there is a notification that this person has a shared care plan. Some of them already have them, like a program referred to as the “golden ticket” at Virtua, but eventually, all of them will have it. This will mean that when you open up the chart of a complex care patient, you see a yellow flag, and you go, “Oh, this person has a care plan; let me pull it up.”

Lisa: Since we don’t yet have a way to push the shared care plan to each system’s electronic health record, we share it with our partners in two ways. First, we email out a copy of the plan to all partners, which includes updated action steps and the identified central point of contact. Second, we add every shared care plan to the HIE. It is still important that we find a way for busy providers to access the plan within their own electronic health record, but for now, the HIE serves as a central location where all partners can access the plan.

How will making the care plans accessible across EMRs transform how we provide care?

Lisa: By making shared care plans accessible, we will be able to shift from fragmented, organization-specific interventions to a coordinated, person-centered approach across the healthcare and behavioral health continuum. This allows all partners to respond consistently, reducing duplication of services, minimizing gaps in care, and ensuring that patients receive timely and appropriate support regardless of where they enter the system.

To read more about complex case conferencing as a promising practice, read our brief here.