Strengthening ecosystems of care is the future of the complex care field and the way to address social drivers of health

Camden Coalition staff members cheer with their hands raised at the end of a team huddle
Author
Kathleen Noonan, President and CEO
Date
August 23, 2022
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If you’ve been following the Camden Coalition and our work over the past few years, you may have noticed that we’ve started talking a lot about “ecosystems,” using terms like “complex care ecosystems” and “ecosystems of care.” But what are ecosystems in the context of improving care for people with complex health and social needs? And why do we believe that strengthening ecosystems of care is the future of the complex care field, and a way to better address social drivers of health for everyone?

We define “ecosystems of care” as interdependent networks of organizations and sectors within a community that work collectively to provide care. In a “complex care ecosystem,” these networks would work together to address the root causes of poor health among individuals with complex health and social needs — i.e., those who have  multiple chronic physical and behavioral health conditions as well as social barriers to well-being.

In our work providing high-touch care management in Camden, we’ve learned that success in complex care is not achievable for one system or one organization by itself. When our program participants graduate from one of our care management programs, they still need ongoing, quality care to manage their chronic conditions, as well as continued access to housing, food, transportation, and social support. Care coordination on a person-by-person basis is only the first step — ultimately, the systems themselves need to work in coordination around the needs of the people they serve.

Strengthening Camden’s care ecosystem

In Camden, we learned quickly that sharing data is essential for organizations to provide coordinated care. In 2010, we launched the Camden Coalition Health Information Exchange (HIE), which now includes over two million unique patient records that are securely accessible to 35 organizations in South Jersey. Our HIE allows us — as well as other health systems and community-based organizations in the region — to create shared workflows that can identify patients in need in real time and quickly link them to care. In 2016, we launched My Resource Pal, a social services search platform powered by findhelp that contains up-to-date information on vital community resources in one central location. Lastly, since their establishment in 2007, our cross-organizational, monthly Camden Care Management Meetings bring together providers from across the Camden area to share information and available resources, and to identify ongoing needs.

In 2020, our ecosystem approach in South Jersey was formalized by state legislation that named us one of New Jersey’s four Regional Health Hubs. As a Regional Health Hub, we act as a bridge between New Jersey’s Medicaid Office and the managed care organizations, health systems, and community-based organizations that serve Medicaid patients in much of South Jersey. Our role is to support South Jersey’s ecosystem of care: ensuring the timely flow of information and resources, and bringing partners together to tackle priority issues. This structure served our region well throughout the COVID-19 pandemic, as we were able to respond quickly and collaboratively to target testing, vaccination, and education efforts where they were needed most. 

Crucially, it is our program participants, care teams, and community members who identify the gaps in care that we work with our partners to close. We believe that people with lived experience are best positioned to identify the shortcomings of our current, fragmented systems, and to imagine creative solutions. When an ecosystem of care is designed to work for the most marginalized individuals with the most complex needs and most barriers to quality care, it is likely that it will work for everyone.

Ecosystems at the center of our 2022-2025 strategic plan

As we’ve learned about what works (and what doesn’t) here in Camden, we’ve shared our lessons with communities around the country to support them in building and strengthening their own ecosystems of care. Our newly released 2022-2025 strategic plan provides a framework for us to continue to do so, along with an ambitious goal to confront inequities and system failures by strengthening the ecosystems of care for 500 communities in Camden, across NJ, and around the country over the next three years.

In order to achieve this goal, we will:

  • Ensure equitable policies and practices are embedded in all aspects of the Coalition’s work
  • Demonstrate what works for people with complex needs
  • Expand the evidence base for complex care using measures that matter to our participants and partners
  • Be the expert by disseminating knowledge, supporting adoption and training the field on what works in advancing whole-person care
  • Enhance the organizational alignment between our local and national work to accelerate scaling of best practices

We have also developed a framework for measuring progress toward creating strong and equitable ecosystems of care. Success will be measured along six domains:

  • Workforce
  • Services
  • Data and measurement
  • Leadership and governance
  • Payment and funding
  • Consumer partnership

Our strategic plan was developed with input from our local and national partners including complex care consumers, as well as our board and staff. 

As part of our strategic plan, we are also unveiling a new mission that we think better encapsulates our work, highlighting the centrality of ecosystems in improving care for people with complex needs: improve the health and well-being of people with complex needs by demonstrating and advancing equitable ecosystems of care

Our vision remains the same, and one we work toward each day: transformed health and social systems that ensure every individual receives person-centered care rooted in authentic healing relationships.

Also, in recognition of the interprofessional and multi-sector ecosystem we are building as a model in Camden, we have decided to no longer refer to ourselves as a coalition “of Healthcare Providers” but rather and more simply to say the “Camden Coalition.” Our care teams have long included non-healthcare providers, and our partners have always included organizations, practitioners, and experts with lived experience from sectors like social care, criminal justice, housing, and education. This shift in naming is simply a reflection of the important role that all members of our coalition – and any coalition – play within a complex care ecosystem.

We are encouraged in our work by the new sense of urgency we hear in conversations happening at the community, state, and federal levels around health equity and addressing social determinants of health. Our two decades of experience in this space have taught us that providing quality, timely care for those who need it most takes a whole community working in tandem. As we continue to innovate and develop new pilot programs that improve the health and well-being of individuals with complex health and social needs, we will be working with our ecosystem partners here in South Jersey and around the country to create the system-level transformations necessary to provide person-centered care, and to learn what makes complex care ecosystems successful. 

 

Are you working to start or strengthen an ecosystem of care in your community? Learn more and find relevant resources on our complex care ecosystems page, and if you’re looking for help on an organizational or system level, check out our technical assistance offerings. If you’re looking to connect with and learn from others across the country who are engaging in similar work, don’t miss Putting Care at the Center 2022, our annual conference for the complex care field, this year in Sacramento, CA, September 21-23. It is not too late to sign up to join us virtually or in person. 

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