In early 2020, a randomized controlled trial (RCT) of the Camden Core Model for adults with complex health and social needs and frequent hospital admissions found no impact on hospital readmissions. Since that time, follow-up analyses have uncovered key takeaways for future complex care program design. Subsequent studies reported that participation indeed led to increased primary and specialty care outpatient visits and that patients who were more engaged in the program experienced fewer hospital readmissions. What lessons do these evaluations, along with insights from care delivery changes, teach us about how to effectively design and tailor complex care programs?

This webinar, made possible through the Seven Foundation Collaborative and hosted by the Better Care Playbook, speakers described how our work has evolved in recent years to more effectively care for adults with complex health and social needs by integrating lessons from this evidence. Our programs bridge individual-level care management and systems-change work to target groups with the highest barriers to engagement in conventional care management programs. These programs include a medical-legal partnership, a Housing First program, and an emergency department-based program to connect patients to outpatient behavioral health care. Panelists offered lessons on how to tailor a complex care program, identify the populations who are most and least likely to engage, and, most importantly, collaborate across organizations on community-level solutions so that care management is not taking place in a vacuum. It included perspectives from a researcher, program administrator, and a community health worker on how to pilot approaches to support improved health and well-being.