The U.S. healthcare system delivers medical, behavioral health, and social services in ways that do not always meet patients’ needs, especially patients who have complex health and social needs.
The Camden Coalition responds to this gap with person-centered programs and new models that address chronic illness and social barriers to good health. Supported by a robust data infrastructure, cross-sector convening, and shared learning, our community-based programs deliver better care to the most vulnerable individuals in Camden and regionally.
Our patient-facing care interventions use “healthcare hotspotting,” which entails using data to identify individuals with frequent hospital use and considerable health and social complexity. Our primary intervention is the Camden Core Model, which provides community-based care management to Camden residents with very complex needs. We also innovate and adapt our interventions to ensure that individuals with unique challenges get the care that they need. Our pilot programs include:
We also developed My Resource Pal, a free, up-to-date database of direct services available to Camden, Burlington, and Gloucester counties.
To shift how care is delivered to people with complex health and social needs, we partner with our network of providers, payers, and consumers to support systems change in Camden and the surrounding region. These practice-facing interventions build the capacity of primary care providers to serve individuals with complex needs:
- Citywide primary care connection: Our 7-Day Pledge program connects hospitalized patients to their primary care physician within seven days of discharge to reduce readmissions and other complications.
- Screening for social determinants: Our Accountable Health Communities program partners with clinical and social service providers across Camden, Burlington, and Gloucester counties to screen individuals for social needs and connect them to the services they need.