Phase 3 of the Camden Core Model: Expanding our intervention and broadly sharing our knowledge (2014-2017)

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 3 of the Camden Core Model: Expanding our intervention and broadly sharing our knowledge (2014-2017),” is the third 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.

During this period, the Care Teams continued to conduct home and community visits and accompany patients to other meetings related to the management of health and social needs.

Care Team members went with patients to their meetings and appointments for primary care; helped with applications for public benefits like food stamps; and provided referrals to social service agencies and housing agencies. They also arranged medication delivery in partnership with local pharmacies, and coordinated care among providers. Some important changes we made during this time include:

Adding a psychologist to the Care Team

Because of our patients’ mental health needs, we partnered with Rutgers University Behavioral Health Care to add a psychologist to our staff. The psychologist evaluated and coordinated care for patients with significant mental health and addiction issues and gave advice to Care Team members for patients with less significant behavioral needs. The psychologist also provided formal training for Care Team staff and community partners. 

Forming a hospital bedside enrollment and engagement team

Until this point, we primarily focused on working with patients after hospital discharge and within the primary care setting. This meant that there were missed opportunities to begin relationship building and goal setting while individuals were still admitted to the hospital, as opposed to waiting until patients were discharged. We decided to add two staff members who were solely focused on working with patients while they were in the hospital. These staff enrolled patients into our model or met with patients who were already enrolled but had readmitted. While this added a layer of complexity because it meant that the hospital-based team would need to hand off the patient to the community-based team, it increased our ability to enroll more patients and build relationships within the local hospitals. It also allowed our community teams to focus on attending home visits and accompanying patients to services within the community. In the end, the change allowed us to become more efficient, gain expertise about how to engage patients in different settings, and strengthen our partnerships with local health system staff.

Building a Housing First program

As our Care Teams continued their community work with an expanded emphasis on social supports, housing surfaced as a major, if not the most significant, barrier to health and stability for our clients. Our data analysis showed that homeless patients had worse outcomes and were less likely to graduate from our program. But wait lists for housing were long and shelter beds were scarce. Simply navigating homeless patients to social services was not helpful, since the services our patients needed were unavailable and the primary care providers we were connecting our clients to were unable to address their housing problems. To fill the gap, in 2015 the Camden Coalition launched a Housing First program, a national model aimed at ending homelessness. A Housing First approach meant that we could help our patients stabilize their housing situations by moving them into permanent housing and providing support services without preconditions such as sobriety or mandated treatment. By mid-2015, the Camden Coalition had received 50 vouchers from the state of New Jersey, which provide market rate payments for housing for up to 15 years. We housed our first patient in November 2015, and by the end of 2017, 39 patients had been housed through Housing First.

Unit availability and landlord willingness to take on these tenants were – and still are – the major limitations in our ability to get patients into permanent housing. Furthermore, we found that legal issues often complicated the use of housing vouchers, and many of our patients were dealing with court matters related to issues such as unpaid child support and other municipal fines and fees that, although civil in nature, could result in jail time. The prevalence of legal barriers in the patient population led us to another insight: the need to clear up legal matters that were excluding people from housing and other benefits. As a result, we began exploring how to build a Medical Legal Partnership at the Camden Coalition.

Connecting patients to primary care after hospital discharge

Our Care Teams also observed that patients were having trouble being seen by a primary care provider within a week of hospital discharge. Despite the Affordable Care Act’s financial incentives available for primary care, most practices in the City of Camden had limited bandwidth for significant organizational change and almost none had enough social work support. Drawing on what we learned serving our patients, we launched the 7-Day Pledge in 2014, a collaborative approach to insuring primary care follow up appointments within 7 days of hospital discharge.  We knew that the primary care providers’ existing workflows were not structured to provide appointments within just a few days, so we worked alongside them to co-design a new process that would ensure the availability of timely follow-appointments. The 7-Day Pledge became our signature clinical redesign initiative, allowing us to strengthen our relationships with primary care providers throughout the Camden area. The results of this program were published in January 2019 in JAMA Network Open. We found that patients attending a primary care follow-up appointment as part of the 7-Day Pledge had fewer 30- and 90-day readmissions compared to patients with less timely or no primary care follow-up. 

Codifying and sharing lessons and knowledge from our work 

After almost ten years of working on the frontlines of healthcare delivery with the most complex patients, we began to synthesize key lessons from our care management and coalition-building work:

Partnering with researchers to conduct a randomized controlled trial

As we refined our approach, we wanted to learn more about how our model could affect patient outcomes. Simultaneously, the Camden Coalition was becoming increasingly seen as an innovator in care management, which led other organizations to become interested in our work. Given that the evidence base for care management interventions did not focus on people with complex needs and there were few randomized controlled trials testing care management interventions for the population we serve, we partnered with researchers from MIT’s Abdul Latif Jameel Poverty Action Lab to investigate the impact that the Camden Core Model has on patients’ readmission rates. We anticipate sharing the study results when they are available.

Developing the COACH framework for patient engagement

We learned that our patients seemed to do better when they developed what we call “authentic healing relationships” with our Care Team — a secure, genuine, and continuous partnership between the Care Team Member and the patient. Our knowledge of the techniques and practices that worked best with patients, including authentic heali COACH is our framework for building authentic healing relationships with patients that empower them to take control of their health. COACH stands for: C: Connect tasks with vision and priorities O: Observe the normal routine A: Assume a coaching style C: Create a backwards plan H: Highlight progress with datang relationships, evolved into what we now call COACH. This five-part framework trains staff to problem-solve with patients to effectively manage their chronic health conditions and reduce preventable hospital admissions.  Once the Care Teams were routinely practicing COACH, we worked with researchers from PolicyLab at the Children’s Hospital of Philadelphia to develop a COACH manual that outlines the approach and standardizes how we use it with our patients.

Solidifying our care planning approach and launching My Resource Pal

During this time, we also developed a care planning toolkit which captured, synthesized, and documented Care Team members’ individual knowledge around how to implement our 16 care domains. This process allowed us to standardize the methods and resources that staff use over the course of the Camden Core Model and develop a comprehensive resource library of all services available in the Camden region. Once we completed the toolkit, we were able to ensure continuity and institutional knowledge. We also wanted to share this knowledge, and our framework for care planning, with the broader Camden community. 

 The Camden Coalition’s 16 care domains The 16 care domains are the areas in which we work on behalf of our patients. Patients set their own goals as part of the Camden Core Model, and we use the care domains to help organize the work that needs to be done. Addiction Advocacy and Activism Benefits and Entitlements Education and Employment Connection Family, Personal, and Peer Support Food and Nutrition Support Health Maintenance, Management and Promotion Housing and Environment Identification Support Legal Assistance Medication and Medical Supplies Mental Health Support Provider Relationship Building Reproductive Health Transportation Support Patient-Specific Wildcard (i.e., patients’ unique needs that do not fit neatly into any of the other categories)

We then partnered with Aunt Bertha, a public benefit company, that has built a comprehensive, user-friendly, online social services database to host our knowledge of area resources categorized using our 16 care domains on the website My Resource Pal (formally My Camden Resources). The site is free and accessible for both individuals looking for services as well as providers looking to help connect clients to services. Providers and individuals can enter their zip code and find an up-to-date list of services providing food, health, housing, transportation, employment, and more. We train our partners to use the site to connect their patients to resources. 

Creating the National Center for Complex Health and Social Needs

Finally, we launched the National Center for Complex Health and Social Needs (the National Center) as an initiative of the Camden Coalition in 2016 to share our experience in Camden with the emerging field of complex care and highlight the latest complex care innovations and breakthroughs from other communities across the country. The National Center serves as a professional home for individuals and organizations caring for people with complex health and social needs, uniting and amplifying their efforts to improve care nationwide. Each year, the National Center hosts Putting Care at the Center, a conference for innovators and advocates for healthcare delivery reform to create a shared agenda for the emerging field of complex care.

Read Part 4: Creating an ecosystem for complex care

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