Frontline ECM/CS providers have been given a difficult task under CalAIM. Building relationships and changing behaviors is hard, particularly with populations with high rates of trauma, poverty, substance use disorders, and a deserved mistrust of the systems they interact with.

Providers need training that equips their teams with new skill sets, attitudes, and knowledge to better care for individuals with complex needs.

The Camden Coalition is at the forefront of this work. In 2020, we unveiled the core competencies for frontline complex care providers — a set of skills all frontline complex care providers need regardless of discipline, profession, and context. These competencies have emerged as an industry standard and continue to inform and structure our teaching and training offerings.

Our off-the-shelf offerings in this domain include:

1. COACH: a patient engagement and care delivery framework for training multi-disciplinary frontline teams, equipping staff with a shared language and relationship-based lens to develop person-centered care plans. (virtual, instructor-led)
2. RELATE: a reflective supervisory framework for training supervisors of frontline teams, equipping supervisors with the skills necessary to support, develop, and sustain multi-disciplinary care teams. (virtual, instructor-led)
3. The Complex Care Certificate: nine online courses which train frontline providers in the competencies required to provide high-touch care coordination for individuals with complex health and social needs, including all populations of focus. CEUs available. (self-paced)
4. Delivering whole person care for people who use drugs: a stigma-free, whole-person model for training staff that work with individuals who use drugs. (virtual, instructor-led)
5. Skills labs: targeted, in-depth trainings on core skills of high-touch care coordination, such as trauma-informed care, motivational interviewing, de-escalation, and more. (self-paced)

Whether you’re a new ECM or CS provider or have an existing program, our team of experts can help design and improve your care management workflow. Our extensive experience working with individuals with complex needs and implementing community-based complex care programs is based on our nationally-recognized Camden Core Model.

We know that health and social needs cannot be separated from one another. But as those needs overlap the required solutions get more complicated. That’s why we have both hands-on and off-the-shelf offerings to meet your specific needs in these two benefits covered by Cal-AIM.

Enhanced care management

Strengthen your ECM program by identifying and deploying best practices to engage and care for individuals with complex health and social needs. Our hands-on TA can guide you through what it takes to design and implement sustainable care management plans, foster team collaboration, create custom tools and guides, and more, all while identifying and minimizing pain points.

Our off-the-shelf offerings in this domain include:

• Activating home and community-based care (new ECM providers)
  • Goal: Develop efficient workflows, staffing structures, and safety measures for effective home and community-based care.
• Strengthening oversight and quality enhancement tools (existing ECM providers)
  • Goal: Increase program effectiveness, efficiency, and revenue generation through data-driven quality improvement systems and processes.
• Fostering effective team collaboration and cooperation (existing ECM providers)
  • Goal: Improve care delivery and provider satisfaction through clarification of team roles, routines, and norms.
• Developing ECM strategies for target populations (existing ECM providers)
  • Goal: Create and activate workflows that leverage existing resources within your community to support your target population(s).

 Community supports

Through hands-on TA, we can help design and streamline the implementation of your social services. Among other types of support, we can find alignment with outside stakeholders, strengthen data management and collection, and create new audit and compliance functions. In these projects, we can coach you through new and streamlined processes that allow you to advance your organization’s mission.

Medi-Cal recipients should be able to navigate a range of services and providers across multiple sectors with confidence and ease.

Our experts can help you build cross-sector ecosystems of care and coach leaders to develop, strengthen, and operationalize an infrastructure that enables new and existing partners to work together in innovative ways. Augmenting this kind of collaboration with MCPs, counties, and other providers increases your clients’ access to services while minimizing common issues like competing priorities, funding, and staffing limitations that often get in the way of building partnerships.

Our off-the-shelf offerings in this domain include:

• Enhancing services through asset mapping and strategic planning at the community level
  • Goal: Increase the effectiveness and efficiency of your ECM/CS program by leveraging existing resources in your community.
• Establishing and improving structures for multi-organizational alignment
  • Goal: Strengthen your community’s ecosystem by establishing collaboratives tasked with the development, oversight, and improvement of cross-organization workflows.
• Activating community case conferencing
  • Goal: Improve care delivery for complex populations by establishing routine, multi-organization case conferencing meetings.

For hands-on TA, our approach begins by understanding how you serve specific populations of focus and mapping the different sectors that those populations interact with. From there, we support your team and your partners in building practices that support sustained, multi-organizational collaboration, structural enhancement, and strategic planning to harness the resources available in your community.

Transparent, inclusive processes grounded in robust data sharing are critical to the success of any multi-organizational collaboration.

For over 10 years, the Camden Coalition has managed the region’s Health Information Exchange (HIE), which provides the real-time data providers need to serve their patients. Launched in 2010, the Camden Coalition HIE collects secure medical information from a variety of sources, including regional hospitals, primary care providers, correctional facilities, and other licensed healthcare facilities and providers. The Camden Coalition HIE is the primary source of interoperability in the region and the backbone of numerous regional healthcare initiatives.

We have the experience and resources to support organizations across the country in enhancing their data sharing infrastructure. Whether you’re looking for improved sharing of patient data and care plans, data-driven patient identification strategies, or better technology infrastructure to interface with patients, we can support you.

Our off-the-shelf offering in this domain includes:

• Assessing opportunities for enhanced data sharing and interoperability
  • Goal: Maximize access to, and use of, cross-organizational data for patient identification, engagement, and care.

We can help you engage your clients and community members to build authentic, impactful, and mutually beneficial partnerships with people with lived expertise. The Camden Coalition is at the forefront of efforts within healthcare to improve health equity by strengthening care delivery for communities harmed by structural racism and poverty.

Addressing marginalized communities’ well-deserved mistrust of the health system and social services requires that health and social care programs understand, respond to, and meet their needs. To get there, people with lived experiences must be equal partners in the work. We’ve built initiatives, such as our National Consumers Scholars program, that connect people with complex health and social needs to the decisionmakers designing programs and implementing policies that affect them and their communities.

Our off-the-shelf offerings in this domain include:

• Integrating people with lived experience into program delivery and oversight
  • Goal: Improve program design and organizational strategy by incorporating lived experience perspective into leadership bodies.
• Fostering ongoing partnerships with community residents
  • Goal: Deepen connection and trust among members of the community through an engagement strategy that leverages patient voice and community leadership.

Adventist Health hired us as they prepared to launch risk-based Medicaid contracting in California. In the lead up to that launch, there was a consensus in the region that the system of care delivery was underfunded, antiquated, and dysfunctional. The result was Project Restoration, an initiative we co-designed and implemented with a team of regional stakeholders in Lake County, CA, which quickly became a community-wide model for patients with complex needs.

A rural critical access hospital, Adventist Health serves communities with some of the worst health outcomes in California, which are compounded by devastating wildfires and a limited range of resources. With our partners, Project Restoration was developed to meet the complex needs of those vulnerable community members, who reported disproportionately high interactions with the healthcare, EMS, and criminal justice systems.

Through careful study of available cross-sector data and other available evidence regarding the state of care management and delivery, our team of partners were able to recommend and implement pilot projects and policy changes to create more efficient and effective services in the region.

As a result of these changes, Lake County, CA observed the following impact:

Consequently, our primary client was promoted to lead community benefits across the enterprise. Today, we continue to support her and her team as they scale their complex care approach to over 40 markets, while developing Adventist’s own consulting capacities to spread complex care to other health systems.

“The Camden Coalition is the preeminent leader in redefining care for those with complex health and social needs. Their experts mentored our leaders and community-based teams to develop trustworthy collaboratives and implement effective solutions to fill local gaps.”

In April 2021, our National Center for Complex Health and Social Needs convened an 18-month long Ecosystems Learning Collaborative. This action-focused opportunity offered representatives from health systems around the country to collaborate with peers and technical experts on expanding and sustaining cross-sector partnerships to better care for individuals with complex health and social needs.

From this initiative, a new ecosystem of care based in San Diego, CA was developed.

Ecosystems of care result from intentional inter-professional and inter-organizational collaboration to create a network of interconnected programs and services to better address the root causes of complex health and social needs in a community.

In San Diego, the ecosystem of care included:

• Rady Children’s Hospital – San Diego
  • California Kid’s Care
  • Center for Healthier Communities
• Copley-Price YMCA
• The Urban Collaborative Project
• UCSD Ma Fresco Prescription Program

California Kid’s Care, a demonstration pilot launched by Rady Children’s Hospital in 2018 to provide care for Medicaid-eligible children, joined our Ecosystems Learning Collaborative after successfully facilitating internal and external partnerships to resolve critical member issues. From that experience, Rady partnered with us to build a robust ecosystem of care to foster long-term sustainability and improved emotional and mental-health outcomes for children of families enrolled in Medicaid.

By expanding and reinforcing the community network of social and behavioral health providers, the goal of this ecosystem was to increase the percentage of California Kid’s Care Members rating their overall mental or emotional health as good or excellent from 69% to 72%.

While there was a need to get creative about the path forward and initial hesitancy around how to address social drivers of health, the ecosystem identified three major successes they accomplished from their work.

1. A more community-focused approach: as the team became more intentional about how programs are built and how to incorporate the lived experience of families, there was a clear shift from a purely medical approach to a more community-focused approach.
2. Increased support for existing services: in helping programs to secure source funding and expanding existing grant programs, hospital support systems, such as ChildLife, a resource for emotional and mental well-being, expanded the availability of their services.
3. Re-vitalized collaboration: as they incorporated the ecosystems approach, the team began looking for new community partners to better serve the needs of their families. Leaving their comfort zone expanded their outreach efforts and brought new people and services into the ecosystem to better meet the needs of children and their families.