Moving out of the “fix it” framework towards sustainable change
Person-centered care management for individuals with complex needs.
Following the principles of trauma-informed care and harm reduction, our goal is to empower patients with the skills and support they need to improve their health and well-being.
We use data to identify eligible individuals, most often through our Camden Coalition Community Health Information Exchange, using criteria that indicate considerable medical and social complexity. We then meet potential participants in-person, usually at the hospital bedside, to enroll them in the program.
Once participants are enrolled, an interprofessional team of nurses, social workers, and community health workers visits them in the community, helping them to reach their own goals for health and well-being. Our COACH framework guides our team in creating authentic healing relationships that build participants’ self-efficacy.
Depending on the participants’ goals and needs, care team members may help reconcile their medications, accompany them to doctor’s visits, and link them to social and legal services. Some of those social and legal needs can be met by more specialized programs within the Camden Coalition, like our Housing First program or Medical-Legal Partnership. For others, we connect them to services provided by our community partners.
Participants graduate from the Camden Core Model when they reach their goals through a combination of skill-building and connection to ongoing supports.