In early 2020, a randomized controlled trial (RCT) of the Camden Coalition’s care management program for adults with complex health and social needs and frequent hospital admissions found no impact on hospital readmissions. Since that time, follow-up analyses have uncovered key takeaways for future complex care program design. Subsequent studies reported that participation indeed led to increased primary and specialty care outpatient visits and that patients who were more engaged in the program experienced fewer hospital readmissions. What lessons do these evaluations, along with insights from care delivery changes by the Camden Coalition, teach us about how to effectively design and tailor complex care programs?
This webinar, made possible through the Seven Foundation Collaborative, described how the Camden Coalition has evolved its programs in recent years to more effectively care for adults with complex health and social needs by integrating lessons from this evidence. Camden Coalition’s programs bridge individual-level care management and systems-change work to target groups with the highest barriers to engagement in conventional care management programs. These programs include a medical-legal partnership, a Housing First program, and an emergency department-based program to connect patients to outpatient behavioral health care. The webinar offered lessons on how to tailor a complex care program, identify the populations who are most and least likely to engage, and, most importantly, collaborate across organizations on community-level solutions so that care management is not taking place in a vacuum. It will include perspectives from a researcher, program administrator, and a community health worker on how to pilot approaches to support improved health and wellbeing.
Presenters included Natasha Dravid, Senior Director of Care Management and Redesign Initiatives, Camden Coalition; Dawn Wiest, Director of Research and Evaluation, Camden Coalition; and Jessica Cordero, Community Health Worker, Camden Coalition. Robyn Golden, Associate Vice President of Social Work and Community Health at Rush University Medical Center, shared reactions on how the results from the RCT of the Camden Core Model and other evaluations are shaping clinical practice.