From siloed systems to ecosystem: The evolution of the Camden Coalition’s complex care model

Author
Kathleen Noonan and Kelly Craig
Date
July 16, 2019
Renee talks to care team members in the Camden Coalition office
September 27, 2022
RELATE: Helping supervisors support their frontline staff — and prevent burnout
Learn about our new stand-alone training, designed specifically for supervisors of frontline complex care team members.
Paula Derrow, Freelance Writer
Marisol writes in a notebook after talking on the phone with a patient
September 7, 2022
Building genuine patient relationships over the phone
The pandemic and a telephonic social needs navigation program showed how to build authentic healing relationships over the phone.
Marisol Caban, Associate Director of Care Management Initiatives
Author Avani Kashyap at the Camden waterfront
August 31, 2022
Good intentions aren’t enough: Escaping the mindset of poverty porn
A Camden Coalition summer intern reflects on the difference between idealism and solidarity.
Avani Kashyap, Student, Washington and Lee University
Camden Coalition staff members cheer with their hands raised at the end of a team huddle
August 23, 2022
Strengthening ecosystems of care is the future of the complex care field and the way to address social drivers of health
Care coordination on a person-by-person basis is only the first step — which is why ecosystems are at the center of our 2022-2025 strategic plan.
Kathleen Noonan, President and CEO
A patient holds her baby
July 27, 2022
Supporting pregnant and parenting people who use drugs: A new toolkit and webinar
Everyone deserves access to quality healthcare and social support without the fear of criminalization.
Emily Wasuna, Program Manager for Field Building and Resources; Kyli Rodriguez-Cayro, Content Manager, Overdose Prevention Program at Vital Strategies
July 12, 2022
Words matter for inclusive care
How we talk about individuals in verbal and written form can make or break a medical experience before patients even enter the exam room.
Erica LaRocca, Program Assistant for Clinical Redesign Initiatives

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 four-part series, we describe the phases of our work as we addressed challenges and tested new solutions.

  • Part 1 describes our roots as coalition builders in Camden City and early work in care provision and management for patients with complex health and social needs (2007-2011).
  • Part 2 details how we refined our ability to identify high-needs patients through data (“healthcare hotspotting”) and adapted our care model to link patients back to permanent primary care or specialty providers (2012-2013).
  • Part 3 explains the significant changes we made to our care management model to better address and meet social needs, and our efforts to share what we were learning with the field (2014-2017).
  • Part 4 shares our vision for building complex care ecosystems in the Camden region and nationwide (2018 and beyond).

Read the full piece in a brief or on Medium.

Stay Informed

Join our mailing list to get the latest updates sent right to your inbox from the Camden Coalition.

Sign Up