The heart of our work is the Camden Core Model, our signature care management intervention. Following the principles of trauma-informed care and harm reduction, our goal is to empower patients with the skills and support they need to avoid preventable hospital use and improve their wellbeing.
We use data to identify eligible patients, most often through the Camden Coalition Health Information Exchange, using criteria that measure considerable medical and social complexity. Then, we meet patients in-person, usually at the hospital bedside, to enroll them in the intervention.
An interprofessional team of nurses, social workers, and community health workers visits participants in the community, helps reconcile their medications, accompanies them to doctor’s visits, and links them to social and legal services. Over the years, our intervention has evolved to spend as much time linking patients to social support as to healthcare. Our COACH practice guides our team in building authentic healing relationships that build patients’ self-efficacy. We work with each individual to create a customized care plan, centered on their own goals and wishes, that helps them realize their highest level of health and well-being.
The Camden Core Model is not attached to one hospital or health system, since patients with complex needs often engage multiple systems. The model recognizes that much of what drives health takes place outside the four walls of medicine.
While discussions about the social determinants of health are featuring more prominently in the nation’s current health policy conversation, many organizations, like the Camden Coalition, have been working for years to understand and address this intersection. In 2016, we created the National Center for Complex Health and Social Needs as a way to build a field that addresses what we have come to call complex care. The field has yet to discover the full set of solutions that bridges the gaps between medicine, behavioral health, public health, and social services to guarantee better health and well-being, but recent discussions about “social determinants” provide new pathways of hope and inquiry. In the spirit of reflection and continuous learning, we thought it was timely to share the story of the Camden Coalition’s 15-plus years developing a care model that is centered around both health and social complexity. We hope it encourages others to start, continue, persist, or expand this work.
In this brief, we describe the phases of our model as we addressed challenges and tested new solutions.