Reducing hospital readmissions among individuals with complex health and social needs

Analysis shows Camden Coalition’s complex care model results in reduction in hospital readmissions among the most likely to engage patients

Care management & redesign Data analysis & integration Measurement & evaluation Quality improvement

September 12, 2023

Lisa Miller, Director of Communications and Content Development
[email protected]


CAMDEN, NJ, September 12, 2023 – A new study, “Hospital readmissions by variation in engagement in the healthcare hotspotting trial: A secondary analysis of a randomized clinical trial,” shows reduced hospital readmission rates for patients with complex health and social needs who enrolled and were likely to engage in the Camden Coalition’s care management model.

Published in JAMA Network Open, this new analysis shows that the more likely the patient was to engage in the intervention, the greater the reduction in hospitalizations. Among patients who were most likely to engage in care management, the relative 30-day readmission risk for intervention participants was 48% lower than the control group. The relative 90-day readmission risk was 52% lower. The number of readmissions 180 days after hospital discharge was also significantly lower for intervention participants when the study population was narrowed to the cohort most likely to engage.

The research paper was authored by Camden Coalition staff members Qiang Yang, Ph.D, Data Scientist for Research & Evaluation; Dawn Wiest, Ph.D, Director for Research & Evaluation; Aaron Truchil, M.S., Senior Director for Data & Quality; along with John Adams, Ph.D, Professor, and Anna Davis, Ph.D, Assistant Professor, both of Kaiser Permanente Bernard J. Tyson School of Medicine and the Kaiser Permanente Center for Effectiveness and Safety Research. Authors Adams and Davis developed the distillation methodology used in the new analysis and received the 2023 James F. Burgess Methods Article-of-the-Year award for their work.

A 2020 study evaluated the average impact of the Camden model across all participants, regardless of their level of engagement, and found no average improvement in readmissions. This new analysis examines the substantial differences in levels of engagement with the intervention across the various subgroups of the study population. For example, when patients have no permanent housing, it makes referrals and follow-ups more challenging. This new distillation of that data tested for differential impact across subgroups, found those impacts, and helps clarify the path forward.

The study adds to the growing body of literature around the measurement of care management effectiveness and suggests future studies should account for variability in intervention delivery as well as patient engagement.

“By applying the distillation method to the data, we were able to see significant differences between intervention and control group patients in readmission rates and readmission counts,” said study author Dawn Wiest. “We found that the people who were more likely to be engaged had significantly better outcomes.”

“We now have data supporting the effectiveness of the Camden Model, which is benefiting individuals with complex medical and social needs not only in our community, but around the country,” said Camden Coalition CEO Kathleen Noonan. “By demonstrating the association between our care management model, the frequency of engagement, and hospital readmissions, we can build a better roadmap for how to improve our overall complex care ecosystem – so that we can provide resources that keep patients engaged and on the path toward a better life.”

The Camden model follows the principles of trauma-informed care and harm reduction, uses data to identify eligible individuals, and provides a multi-faceted professional team that helps patients to overcome social barriers and effectively navigate their complex healthcare needs.

A copy of the study can be found at





About the Camden Coalition

We are a multidisciplinary nonprofit working to improve care for people with complex health and social needs in Camden, NJ, and across the country. The Camden Coalition works to advance the field of complex care by implementing person-centered programs and piloting new models that address chronic illness and social barriers to health and well-being. Supported by a robust data infrastructure, cross-sector convening, and shared learning, our community-based programs deliver better care to the most vulnerable individuals in Camden and regionally.

Through our National Center for Complex Health and Social Needs (National Center), an initiative of the Camden Coalition, we connect complex care practitioners with each other and support the field with tools and resources that move complex care forward.