Complex care refers to a comprehensive, coordinated approach to managing the health and social needs of individuals with multiple, ongoing, and often serious medical conditions. Interdisciplinary care teams and cross-sector partners collaborate to address the root causes of poor health by delivering person-centered care tailored to each individual’s goals and priorities. These root causes often extend beyond physical health to include social determinants such as poverty, trauma, housing or food insecurity, and limited access to care.

The Camden Coalition provides resources to help healthcare providers understand and implement a complex care approach, offering step-by-step strategies and techniques to ensure that providers meet the needs of individuals with chronic health conditions who face social barriers.

Implementing complex care for better outcomes

At its core, complex care recognizes that numerous interconnected factors influence a patient’s health. By addressing these holistically, it can improve health outcomes, enhance the patient experience, and even help lower overall healthcare costs.

Why complex care is needed

In the US, systems of care — including healthcare, public health, social services, housing, education, and other sectors — often operate in silos, with each focusing on a single need and lacking effective coordination. Individuals with complex health and social needs require integrated support across multiple domains; however, the lack of coordination often prevents them from receiving comprehensive care. As a result, they frequently experience poorer health outcomes and rely on costly, crisis-driven services.

Best practices for complex care delivery

• Person-centered: In complex care, individuals’ values and preferences guide all aspects of their care, supporting their realistic health and life goals. It involves building trusting relationships through empathy, active listening, and cultural humility. It also includes acknowledging trauma and recurring trauma.
• Equitable: Complex care acknowledges the structural barriers to health, including systemic, institutional, and interpersonal racism, bias, and other forms of discrimination, and supports individuals and communities in overcoming them.
• Interdisciplinary team-based approach: Complex care is led by the individual and delivered through interprofessional, non-traditional, and inclusive teams of medical, behavioral health, and social service providers. It works to break down the silos dividing fields, sectors, and specialties, and to build the integrated ecosystem necessary to provide whole-person care. Defining clear roles and communication protocols helps avoid duplication and gaps in care.
• Address social needs and drivers of health: To address social needs and health-related drivers, providers should screen patients for risks such as housing instability, food insecurity, and transportation barriers. Partnering with community organizations ensures connection to needed resources. At the same time, advocating for policy changes targeting poverty, housing, and systemic racism helps address the root causes of poor health.
• Integrated medical and behavioral healthcare: Integrated medical and behavioral healthcare involves embedding behavioral health services within primary or complex care teams to address mental health and substance use needs alongside physical health. The approach utilizes shared care plans and communication platforms to ensure the effective coordination of services and enhance overall patient outcomes.
• Flexible, accessible care models: Flexible care access can be provided through telehealth, home visits, mobile clinics, and community-based settings to meet patients where they are. By reducing barriers like rigid scheduling, excessive paperwork, and language differences, this approach makes care more accessible and inclusive. Emphasizing continuity of care and long-term relationships with care teams helps build trust and supports better health outcomes.
• Data-informed care and measurement: Using risk stratification, care teams can identify patients who are both high-need and high-risk, ensuring they receive targeted support. Key outcomes, including emergency department use, hospital admissions, patient satisfaction, and quality of life, are tracked to monitor progress. Data dashboards, patient feedback, and regular reflection by care teams drive continuous improvement.

Complex care training and implementation

Understanding and implementing complex care principles and best practices begins with proper training and education. Professionals must develop specific communication skills to apply techniques effectively across various settings. Comprehensive complex care training typically includes:

• Online courses and microcourses
• Supplemental activities and extensive resources

The Camden Coalition Learning Center offers comprehensive training opportunities specifically designed to help professionals enhance their understanding and skills in effectively implementing complex care.

For those interested in learning more about complex care, visit the Camden Coalition Learning Center.  The Complex Care Certificate and Skills Lab cover multiple sessions that delve deeply into complex care and best practices.

The Camden Coalition is a multidisciplinary, community-based nonprofit organization working to improve care for individuals with complex health and social needs in the city of Camden, across New Jersey, and nationwide. We develop and test care management models and redesign systems in partnership with consumers, community members, health systems, community-based organizations, government agencies, payers, and more, to achieve person-centered, equitable care.

As one of New Jersey’s four Regional Health Hubs, the Camden Coalition collaborates with regional partners, New Jersey’s Medicaid office, and other state agencies to expand data sharing and collaboration among organizations, ensuring that patients across South Jersey receive seamless, whole-person care. You can visit the Camden Coalition Learning Center to register for on-demand, curated courses that provide skills and resources to develop and grow complex care programs.

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