By Amy Yuen

Since medical school, Tina Ahmadinejad knew she wanted to work as a family doctor helping underserved patients in an urban area. But during her residency at a community health center in Delaware County, she started getting frustrated. Many of her patients had multiple health issues that needed to be addressed or were recent immigrants in need of vaccinations and translation services. “I couldn’t get anywhere with these 15-minute appointments,” Tina recalled. “There’s no time to really do anything besides check someone’s blood pressure and say, ‘It’s good. We’ll keep you on the same medication.”

After residency, Tina became a Complex Health and Social Needs Fellow last June through a partnership between the Camden Coalition and Crozer-Keystone Health System. Although her days are still packed, the fellowship has given her the unique opportunity to practice a team-based, integrated approach to providing care and learn what it takes to build a sustainable complex care program.

Since 2012, family physicians like Tina and nurse practitioners have been getting an immersion in the practices of complex care through this one-year fellowship program. At Crozer-Keystone, they collaborate with a clinical case manager, social worker, psychology students, and medical and pharmacy residents in integrated clinical teams to provide coordinated care to patients with complex health and social needs, and address the root causes of frequent hospitalizations and emergency room visits. The program gives Tina hands-on experience in all aspects of our healthcare hotspotting model — everything from complex case conferencing to data analysis to developing systems to improve care and grow the program.

“Everybody is at the table”

“The importance of team-based care and integrated approaches — people talk about it a lot in healthcare, but I don’t think I saw it until I came here,” said Tina. “It’s a breath of fresh air because everybody is at the table.”

One way the fellows incorporate integrated teamwork into their practice is by running weekly huddles for the interdisciplinary complex care teams serving Medicaid and Medicare patients. Tina teams up with her colleague Rebecca Shames, a nurse practitioner who started as a fellow in January, to lead the meetings, where teams provide patient updates, problem solve, and discuss achievements that patients have made toward their goals. This integrated approach to care has challenged her belief, held by many in medicine, that primary care doctors should be responsible for knowing everything about their patient.

“Before, I felt like I needed to be the social worker and psychologist, and I’d get anxious about it because I don’t know where all the resources are,” said Tina. “But there are people around you to help you with these things. You can work as a team and if they don’t find something, you’ll just be in communication about it. I’ve been better at using the team around me.”

The fellowship program allows practitioners to see the effects of complex care on both an individual and systems level. At the Coalition, Tina conducts research to inform our legislative advocacy efforts aimed to improve care for patients with complex needs. This includes research for increasing support services for participants in our Housing First program and the role of care coordinators in increasing patient care and cutting healthcare costs.

As Tina’s time with the fellowship winds down, she’s looking at places where there is more of a team-based approach or there’s an opportunity to work on population health aspects of things.

“I would have never known the different opportunities out there had I not done this fellowship. I didn’t know there was any other way to practice. It’s been really awesome seeing alternatives and being exposed to this world where people are thinking outside the box. There’s a whole community out there trying to change the system.”

To learn more about the Complex Health and Social Needs Fellowship supported by the Camden Coalition and Crozer-Keystone Health System or to apply for the 2018 cohort, contact the Fellowship Coordinator at or visit

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