This brief describes a radically different approach to addressing the needs of people with complex health and social needs. Sharing detailed information between competing health systems’ emergency department (ED) records would be a non-starter in most regional healthcare markets, but this is where the value of backbone organizations like the Camden Coalition comes in. Our partners want better care for high-needs populations in South Jersey and trust that the Camden Coalition is not trying to steer patients to select health systems or upset important volume targets. As a result, they are willing to work on cross-system efforts. This brief describes those efforts through the lens of a maternal and child health case study.

In a retrospective analysis Camden Coalition Health Information Exchange (HIE) data, we found that there were more than 2,000 pregnant individuals annually across five South Jersey counties who had sought care from one of 13 local EDs but had no record of receiving prenatal care, within the HIE. Some may have sought care elsewhere or perhaps thought it was too early in their pregnancy to seek prenatal care. But for those who wanted and needed care, there was no process in place for tracking or following up with them, and ED staff could only make recommendations that patients seek prenatal care; they didn’t have the means to provide scheduling assistance. We suggested using the HIE to create a daily triage report that flagged people whose pregnancy was recorded in the data feeds from EDs but had no record of receiving prenatal care from an outpatient provider. From there, these flagged patients were assigned to OB/GYN practices affiliated with health systems and local community health centers based on records of where they had previously sought care. This is a strong example of the innovation possible when a trusted convener leverages their position to enable cross- sector collaboration.

We believe this backbone model for turning local innovation into ongoing impact — by collaboratively identifying unmet needs; developing, testing, and refining new approaches; and integrating what works into a region’s care delivery ecosystem — can be replicated in communities across the country.