Complex care core competencies

Skills all team leaders and frontline providers need to provide high quality care

Building the complex care field Education & training Workforce development

Scroll to the Top
Clinical practice for people with complex needs means understanding what ‘health’ actually means to them and what is aligned with their values and desired outcomes. It requires understanding their home and social environment, and having an interdisciplinary team that understands, addresses, and communicates around those needs. Toyin Ajayi, Cityblock Health

Complex care core competencies

The complex care core competencies include:

Each set of competencies captures the knowledge, skills, and attitudes needed by complex care team leaders and frontline practitioners respectively, regardless of geographies, settings, and provider types. Both sets of competencies were developed by a dedicated group of leaders from diverse backgrounds and sectors, and were designed to add to rather than replace discipline- and profession-specific competencies.

For team leaders

The core competencies for complex care leaders are for supervisors, managers, program managers, clinical leads, and directors of teams supporting people with complex health and social needs. The competencies capture the necessary knowledge, skills, and attitudes for successful complex care leaders, who must be able to supervise a team, build culture, improve operations, and build relationships across organizations.

Domains

  • Multi-level advocacy
  • Supervision and development
  • Intentional culture development
  • Program operations and management
  • Building cross-sector ecosystems of care
  • Personal values and ethics

Learn more about the core competencies for complex care team leaders:

For frontline providers

The core competencies for frontline complex care providers capture the necessary knowledge, skills, and attitudes for members of teams or individual practitioners that are working in programs dedicated to coordinating and providing services for people with complex needs. These competencies are also for healthcare, behavioral health, and social service practitioners who may not work in dedicated complex care programs, but regularly encounter people with complex needs.

Domains  

  • Human complexity and context
  • Personal and professional commitment and ethics
  • Person-centered, relationship-powered care
  • Integrated team collaboration
  • Diverse information management
  • Systems complexity and context

Learn more about the core competencies for frontline providers:

Implementing the complex care core competencies

The Complex Care Certificate is a comprehensive online certificate based on the core competencies for frontline providers. It includes nine self-paced courses designed to build frontline providers’ knowledge, skills, and confidence in delivering person-centered care for people with complex needs – regardless of discipline, setting, or geography.

A certificate for complex care team leaders is currently in production. The curriculum will be based on the core competencies for complex care team leaders and appropriate for supervisors and managers from all disciplines in all settings who are overseeing teams and programs supporting people with complex health and social needs. The courses will be available to purchase in fall 2025! Sign up here to be notified about their release.

Working groups and support

The complex care core competencies were developed by two dedicated groups of leaders of diverse backgrounds and sectors from across the country. The working groups provided expert insight by participating in thoughtful debate and multiple rounds of feedback on the competencies.

Team leaders working group

Active: spring-summer 2024

Working group members:

  • Aura Silva, BSN PHN ACM-RN, Care Management Manager, Queen of the Valley Medical Center
  • Carrie Lara, Psy.D., Clinical Director and Head of Behavioral Health, Community Support Network
  • Doreen Glover, LSW, Prevention Manager, Family Resources
  • Heather Thomas, MSW, LSW, Program Supervisor of Pledge to Connect, Oaks Integrated Care
  • Heather Thomas, MSW, LSW, Program Supervisor of Pledge to Connect, Oaks Integrated Care
  • Kathy Burgoyne, PhD, Consultant, Uncommon Solutions
  • Keshana Owens Cody, HRM, HPE, Office of Public Health Workforce Director, New York State Department of Health
  • Kristin Burger, BSN, RN, CCM, ACM-RN, Population Health Strategy Lead, Humana
  • Kymberly Centaro, M-RAS, Housing and Wellness Director, Community Support Network
  • Lakisha Sturgis, RN, BSN, MPH, CPHQ, Director of Community Care Management, Center for Population Health, Temple University Health System
  • Laura Fletcher, LICSW, MPH, Behavioral Health Manager, Boston Medical Center
  • Marisol Caban, Associate Director, Camden Coalition
  • Meredith Jones, MSW, LCSW, APHSW-C, Director of Family Support Service, Transitions LifeCare
  • Ren Pelley, CRSP, Peer Manager, Oaks Integrated Care
  • Salvador Nunez, MSW, Social Work Supervisor, Queen of the Valley Medical Center
Frontline providers working group

Active: winter 2019-winter 2020

Working group members:

  • Mark Humowiecki, Chair, General Counsel & Senior Director for National Initiatives, Camden Coalition
  • Anna Rebecca Boorse Doubeni, Education Vice Chair, Associate Professor of Clinical Family Medicine and Community Health, University of Pennsylvania, Perelman School of Medicine
  • Sara Reid, Lived Experience Vice Chair, Consumer Board Member, Boston Healthcare for the Homeless
  • Anne Whitman, Senior Community Researcher, Center for Excellence for Psychosocial and Systemic Research MGH
  • Barbara Crider, JD, Executive Director, York County Community Action
  • Cheryl Garrels, Community Health Worker, MercyOne Centerville Medical Clinic
  • Farhad Modarai, DO, Associate Regional Medical Officer, CareMore Health – North Carolina
  • Janice Tufte, Patient Partner, Hassanah Consulting
  • Jodie Sevier, Community Health Worker, Clinically Integrated Network- ACO- Des Moines Chapter
  • Jonathan K. Weedman, CCTP, LPC, Vice President, Population Health, CareOregon
  • Lesly Starling, BA, BSN, RN, Complex Care Navigator, Kalispell Regional Healthcare
  • Marsha Johnson, Managing Principal, Health Management Associates
  • Martha Chavis, Executive Director, Camden Area Health Education Center (AHEC)
  • Regina Danielson DNP, MAT, RN, Complex Care Research Nurse, Kaiser Permanente Mid-Atlantic Research Institute
  • Scune T. Carrington, Director, Integrated Care, Massachusetts League of Community Health Centers
  • Tina R. Sadarangani, Assistant Professor, New York University Rory Meyers College of Nursing

The development of the core competencies for frontline complex care providers was also supported by the following associations:

  • America’s Essential Hospitals
  • American Academy of Pediatrics – New Jersey Chapter
  • American Association of Colleges of Pharmacy
  • American College of Clinical Pharmacy
  • American Society for Consultant Pharmacists
  • American Society of Health-System Pharmacists
  • Association of American Medical Colleges
  • Council on Social Work Education
  • National Association of Social Workers
  • National PACE (Programs of All-Inclusive Care for the Elderly) Association

Related resources:

Putting Care at the Center attendees holding the COACH fact sheet
Camden Coalition staff laugh in front of white board covered with post-its
Adding post-it to poster labeled "complex care ecosystem"

Related blog posts: