From siloed systems to ecosystem: The evolution of the Camden Coalition’s complex care model

Phase 1: Directly providing healthcare and building citywide partnerships (2007–2011):

Refining and strengthening the Care Team structure and role

Becoming more data-driven through the Camden Coalition HIE

Phase 2: Using healthcare hotspotting to find patients and adjusting the model to suit patient needs (2012–2013)

Refining the healthcare hotspotting process

Using the Health Care Innovation Award to test changes to our approach

Phase 3: Expanding the intervention and broadly sharing our knowledge (2014–2017)

Adding a psychologist to the Care Teams

Forming a hospital bedside enrollment and engagement team

Building a Housing First program

Connecting patients to primary care after hospital discharge

Codifying and sharing lessons and knowledge from our work

Phase 4: Creating an Ecosystem for Complex Care (2018–2019)

Starting a Medical-Legal Partnership

Establishing Regional Health Hubs to better serve our patients

Strengthening the field of complex care

Looking ahead

About the Camden Coalition

Camden Coalition of Healthcare Providers

Written by

We are a multidisciplinary nonprofit working to improve care for people with complex health and social needs in Camden, NJ, and across the country.

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