Phase 1 of the Camden Core Model: Directly providing healthcare and building citywide partnerships (2007-2011)

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 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.

This piece, “Phase 1 of the Camden Core Model: Directly providing healthcare and building citywide partnerships (2007-2011),” is the first in a four-part series that describes the phases of the Camden Core Model as we addressed challenges and tested new solutions. Read all four sections together in this brief.


In 2002, before the Affordable Care Act and healthcare buzz words like “value-based care,” “bundled payments,” and “social determinants of health,” Dr. Jeffrey Brenner, a family physician in Camden, New Jersey, brought together an informal breakfast group of like-minded clinicians to imagine a better healthcare system. 

Healthcare hotspotting is the use of data to identify and engage patients who are outliers in the healthcare system--usually in terms of cost or utilization. The process reveals patterns within data that point to areas of system failure where individuals' needs are not being adequately addressed.This informal group grew into a citywide coalition of hospitals, primary care and social service providers, and community representatives, eventually calling itself the Camden Coalition of Healthcare Providers. Clinical observation and data analysis guided our work together, giving rise to the practice of “healthcare hotspotting.” We learned that the highest-need patients had the most frequent emergency room (ED) visits and hospital admissions. And as is common across the country, our internal analysis showed that one percent of patients represented 30 percent of hospital costs in Camden. Further analyses found that many patients with frequent utilization not only habitually frequented the ED and hospital inpatient wards for what were considered easily treatable conditions, but were also often seeking care for advanced issues that could have been prevented if diagnosed and treated earlier.

In 2007, this early work of coalition-building and data analysis evolved into a pilot care intervention, which we now call the Camden Core Model, funded by the Robert Wood Johnson Foundation through their New Jersey Health Initiatives. Since then, the Camden Coalition has worked with thousands of people from the Camden region who are struggling every day with chronic health issues, addiction, mental health challenges, poverty, unemployment, housing instability, child welfare issues, and criminal justice system involvement.Complex care addresses the needs of people who experience a combination of medical, behavioral health, and social challenges that result in extreme patterns of healthcare utilization and cost. Complex care works at the personal and systemic levels, coordinating care for individuals while reshaping ecosystems of services and healthcare. It is person-centered, equitable, cross-sector, team-based, and data-driven. Alongside pathbreakers who were building programs for home visitation, care management, and hospital-to-home transitions, we have focused solely on serving people facing the most complex medical and social challenges using an approach we call complex care.

Our work on the ground over the past 12 years has given the Camden Coalition a deep understanding of the challenges and barriers that make success difficult, especially around the burdens of discrimination and inequity that were in place long before many of our patients were born. With that in mind, we have continually innovated, moving into new models of care and refining our approach and theory of change based on that experience.

The healthcare field is now discussing social determinants of health, the underlying conditions that affect health, differently than it did back when the Camden breakfast group started meeting. Given this, we thought it would be useful to reflect on how our approach has evolved in light of the significant challenges we have encountered serving our clients in Camden, and the opportunities presented by this emerging conversation.

We are quite sure that we have yet to discover the full set of solutions that bridge the gaps between medicine, behavioral health, public health, and social services to guarantee better health and well-being. But there are many pathways of hope and much to be learned. The story of the Camden Core Model’s evolution is testament to our willingness to iterate and change based on what we learn. This is the story of the first phase, in which we move from this informal breakfast meeting to directly providing home-based patient care and established the Camden Coalition Health Information Exchange. 

We have yet to discover the full set of solutions that guarantees better health and well-being.

— Kathleen Noonan and Kelly Craig

Phase 1: Directly providing healthcare and building citywide partnerships (2007-2011)

In its earliest form, the Camden Coalition’s care model was a partnership between a nurse practitioner, a social worker, and a part-time community health worker. We called this partnership our “Care Team.” Through home and community-based visits, the Care Team directly provided prescribing and treatment for individuals experiencing frequent emergency department or inpatient utilization. The Care Team’s broader goal was to figure out what was driving patients’ emergency department and inpatient utilization and, when appropriate, redirect patients to primary care and specialists. The Camden Coalition’s work during this time was featured in a 2011 New Yorker article by Atul Gawande, which brought national attention to our intervention and healthcare hotspotting.

Refining and strengthening the Care Team structure and role

Providing home-based care allowed us to more directly meet our patients’ healthcare needs. However, because patients were receiving a type of concierge home-based service through our nurse practitioner, they did not want to visit providers’ offices. We realized that we were creating a new silo by duplicating services that were available through a more stable relationship with primary care practices or appropriate specialists. Thus, we decided to move from a prescribing-treating relationship to a more coordinating and supportive role that worked alongside office-based primary care providers. We substituted the nurse practitioner with a registered nurse to lead the Care Team since prescribing was no longer part of our model.

Becoming more data-driven through the Camden Coalition HIE

At that time, we were also identifying patients almost exclusively through referrals, in part through the connections we made as part of our citywide Camden Care Management Meetings. While the referral process was useful in developing very strong partnerships, it did not consistently identify the patients who were incurring high utilization and high healthcare costs, which was the patient population we wanted to serve. 

We also believed duplicative services and higher costs were at least partially related to hospital and other outpatient providers’ inability to view clinical information about the care that their patients were receiving from other facilities. Therefore, we established the Camden Coalition Health Information Exchange (Camden Coalition HIE), a web-based portal directly integrating real-time alerts and patient medical information, such as admission and discharge information, labs and radiology, from the city’s major hospitals. By raising awareness of the need to see data from other providers and building relationships with regional health systems, we established the Camden Coalition HIE as a centralized patient data repository for care providers in Camden. 

We quickly realized that the utilization data housed in the HIE, if analyzed with patient complexity in mind, offered a powerful alternative to word-of-mouth patient referrals. Using utilization as a proxy for high healthcare costs allowed us to conduct healthcare hotspotting more efficiently. The Camden Coalition HIE has become central to our ability to identify patients in real-time who need more intensive care management. 

Read Part 2: Using healthcare hotspotting to find patients and adjusting the model to suit patient needs

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