By Amy Yuen

Individuals with complex health and social needs are more likely to access care from multiple entry points (hospitals, specialist, primary care, social services, and more). This puts the onus on the patient to retain and effectively communicate nuances of their care to each new provider they encounter. The way our health care system is set up is also a challenge for providers; it’s hard to address a patient’s needs when they don’t have a complete medical history.

One way we are elevating health holistically is by convening stakeholders to pilot and co-design new interventions and refine existing models. We believe the best way to address these gaps in care are to innovate in the following areas:
• Create opportunities for providers to cross-collaborate
• Generate authentic-healing relationships between patient and providers
• Create a “no wrong door” policy by meeting patients wherever they are

Here are two examples of how we are partnering with health care and social service providers and public institutions to spark new innovations to improve complex care across Camden:

Partnering with Camden County Re-Entry Committee
Meeting patients at the county jail

Camden RESET (Re-entering Society with Effective Tools) partners with the Camden County Re-Entry Committee to discover and address systemic barriers faced by patients who experience frequent hospital and jail utilization.

RESET follows the Camden Coalition care management model, but expands where we meet eligible patients. Historically, our staff has engaged patients at their hospital bedside. RESET allows our care team to engage patients, who qualify for our intervention, at the Camden County Jail.

Camden RESET uses real-time data from jails and hospitals to identify people with both frequent hospital readmissions and jail stays. Our enrollment team engages eligible candidates at Camden County Jail and offers them the opportunity to participate in our care intervention. If they choose to enroll, they begin the intervention immediately while in jail and continue the program after they are released. A dedicated team of nurses, social workers, and community health workers empower them to address their medical, behavioral, and social barriers to wellness, accompany them to appointments, and connect them to social services.

“We’ve had a positive experience building relationships with participants, advocates, officers and staff at the jail,” said Bill Nice, Program Manager of Innovation Operations at the Camden Coalition. “We’re seeing lots of excitement from all those involved. The participants we’ve enrolled have spoken a lot about making changes in their lives. They often thank us for coming into the jail to help them work on the goals they feel will better their lives. We thank them for sharing their story, and for allowing us to work with them.”

To date, six participants have enrolled in the program since we started in December. Our end goal is to help patients gain the skills and support they need to avoid arrests and preventable hospital admissions, and improve their wellbeing.

Partnering with social service and behavioral health providers
Meeting patients in primary care

Individuals who face housing instability, lack access to transportation, and have mental health or substance use disorders–are more likely to experience emergency care. But within the four walls of the doctor’s office, many health care providers lack the resources and training to screen for and address these needs that are often thought of as “non-medical”.

“All the things that aren’t medical–the social and behavioral aspects of life–were previously considered separate from health care,” said Carter Wilson, Associate Director of Clinical Redesign Initiatives for the Camden Coalition. “If primary care is meant to be the health home for patients, then primary care providers need the skills, protocols, processes, and connections with social service agencies to address the social and behavioral barriers to health.”

To identify and address the root causes that lead to extreme patterns of emergency care, the Coalition is developing a pilot program that seeks to improve collaboration between local primary care, social services, and behavioral health providers, and their patients who experience high rates of emergency care. Twelve primary care providers and four social service providers–Oaks Integrated Care, Planned Parenthood, Holy Redeemer Home Health, and Northgate II–are partnering with the Coalition to develop the program.

Our care management team is working with providers so they can better understand and screen for the social factors that contribute to extensive emergency department utilization–namely, housing instability, transportation, food insecurity, interpersonal violence, and utility needs. They have also been modeling our key care principles–the COACH framework, trauma-informed care, harm reduction, accompaniment, and motivational interviewing. These key care principles will give providers the skills they need for co-creating goals with patients that may encompass more than traditional medical needs.

Primary care providers have received an initial list of patients who have experienced frequent and persistent emergency department utilization. Each provider is now scheduling interviews with three selected patients about their priorities, social supports, relationships with their primary care provider, and what drives their frequent trips to the emergency department. To help practices prioritize screening and engaging with patients on the social correlates of health, the pilot program will give providers financial incentives for conducting targeted patient outreach, care planning, and care coordination with other health care and social service providers. We hope that findings from the pilot will help inform the design of a city-wide program to engage patients who experience high rates of emergency care.


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