At the Camden Coalition, we have continued to test and improve our person-centered care management model since we began this work over 20 years ago, using data — both quantitative and qualitative — to refine how we care for individuals with complex health and social needs and help them navigate our fragmented health and social systems.

Care management, though, has always just been our starting point. As we work with individuals to meet their goals, we also learn where they face systemic barriers to improved health and well-being. Then we continually advocate for the development of ways to mitigate those barriers. Our end goal is a dynamic, coordinated ecosystem of care that works seamlessly for our whole community.

Creating new avenues to address needs beyond healthcare

Care management is of limited value if there is nowhere to navigate people to. Many of our participants have struggled with homelessness and housing insecurity for years or even decades, facing years-long wait lists to access housing they could afford. Our Housing First program brought together six community-based organizations to streamline the housing process and, to date, the program has secured permanent housing and wrap-around support services for 88 participants and counting, which in turn has resulted in a 62% average reduction in inpatient and Emergency Department utilization.

Many of our participants also faced legal barriers to health and social stability, including an inability to access benefits, evictions, or outstanding court fees or warrants. We launched a Medical Legal Partnership (MLP) with Rutgers Law School, embedding attorneys into the care team to help participants resolve legal matters. In 2022, we partnered with Cooper Center for Healing to provide legal services for their clients who were seeking treatment for addiction. To date, we have received over 250 referrals from Cooper for individuals needing help with civil and criminal legal matters that threatened to derail their progress.

Coordinating operations, not just appointments

We also learned that coordinating care on a individual basis doesn’t change how fragmented the system is for the next person in need. Our 7-Day Pledge program showed how building new workflows that connected patients to follow-up primary care within seven days of hospital discharge resulted in significantly lower rates of hospital readmission.

For many people, particularly those with mental health or addiction issues, if follow-up appointments cannot take place quickly, they may not take place at all. We used what we learned from the 7-Day Pledge to launch Pledge to Connect, working with a local health system and a community behavioral health provider to connect ED patients with behavioral health needs to timely outpatient care. To date, 100% of patients who were interested in follow-up behavioral health services have been offered appointments and the program is now expanding to include additional health systems and behavioral health providers across South Jersey. Pledge to Connect was named one of ten national winners of the the Substance Abuse and Mental Health Services Administration (SAMHSA) Behavioral Health Equity Challenge.

Building ecosystems of care

Our experience has taught us that better outcomes for the population we serve will not be accomplished by any single health system, community-based organization, or social service agency. It will take organizations, systems, agencies, and residents working together across a community in a coordinated, interdependent ecosystem.

To make that vision a reality on a statewide scale, we helped develop New Jersey’s unique Regional Health Hub (RHH) model. In 2020, we became one of the state’s four Regional Health Hubs, serving as an intermediary between the state government, Medicaid recipients in our South Jersey region, and the organizations that serve those community members. The RHH model allows us to truly act as an ecosystem, with new avenues for data-sharing, collaboration, community feedback, and flexible disbursement of funds.

For example, the RHH model enabled us to shift nimbly in response to the COVID pandemic. We were able to coordinate and accelerate messaging and outreach, focus testing where it was needed most, deploy trusted messengers to combat misinformation, and achieve a vaccination rate of 80% at the end of 2022.

Meanwhile, we launched new pilots to connect whole swathes of our community to behavioral healthcare, pregnancy care, legal services, and addiction treatment; supported providers in screening tens of thousands of community members for social needs; and continued to grow the region’s connectivity through the Camden Coalition Health Information Exchange and a social services search and referral platform called My Resource Pal. We are now using the RHH infrastructure to ensure that South Jersey residents retain access to healthcare coverage during the Medicaid redetermination process.

Moving forward

In a study published in June, we found that receiving a higher “dosage” of our care management intervention was associated with lower hospital readmission, reaffirming the importance of secure, genuine, and continuous care relationships. It was very gratifying to see those results and we will have more data to share soon.

We are also working to make sure that the way we evaluate our care management outcomes is as person-centered as the care we provide. In partnership with the National Committee for Quality Assurance (NCQA), we are currently refining and testing a measurement methodology that can be tailored to a participant’s self-identified goals.

“We have never rested on our reputation,” notes Camden Coalition President and CEO Kathleen Noonan. “Our work has evolved and our community has grown, but we remain committed to the same goal we have always had: transforming our communities’ health and social systems to ensure every individual receives person-centered care rooted in authentic healing relationships.”

A re-airing of a 2020 podcast on Tradeoffs will feature an update on one of program participants who was connected to stable housing and no longer cycles in and out of the emergency department.