Resources

This blog post features a conversation with Lauran Hardin, Senior Advisor of Partnerships and Technical Assistance at Camden Coalition, who explores the use of asset mapping to build stronger ecosystems of care, address the root causes of repeated hospital utilization, and improve care delivery for individuals with complex health and social needs.
It is widely recognized that good outcomes for patients with complex care needs are achievable when health care providers work locally and in tandem with community, government, and other partners...
This blog post features a conversation with Victor Murray, Director of Field Building and Resources for the Camden Coalition of Healthcare Providers, explores the tension between health systems and community-based organizations and discusses strategies for successfully navigating it.
This resource describes a quasi-experimental study evaluating the effect of a transitional care program that involved rapid primary care follow-up for Medicaid and Medicare patients with complex needs...
This blog post explores the Camden Coalition of Healthcare Providers’ Health Information Exchange, a web-based application that gives providers across health systems real-time access to medical information for patients with complex needs.
In an environment where social determinants are playing more of a role in conversations about improving health outcomes, it is critical for the health care and social sectors (which often take the form of local community-based organizations, referred to as CBOs) to build mutually beneficial partnerships. This play outlines steps to help health systems and CBOs build relationships that draw on each other’s strengths, put patients first, and support ecosystem development in local communities. DOWNLOAD AS A PDF »
Access to a health care data-sharing platform can help social service providers better understand and address issues that lie at the intersection of their clients’ social and medical wellbeing. It can: (1) provide insight into relevant details of the medical situation that their client is facing; (2) help the social service organization identify clinicians who may be valuable partners in the individual’s care; and (3) enable them to access documentation that can help them better advocate for the client. The goal of this play is to help health systems provide access to health-related data to...
The challenge of managing Medicare patients with multiple health conditions is familiar to most providers. According to recent data from the Centers for Medicare and Medicaid Services (CMS), two-thirds of Medicare patients have two or more chronic conditions. Establishing treatment guidelines for every condition and for every patient is challenging for a multitude of reasons. A recent study estimated that 37 percent of the average family physician’s time is spent on chronic care, with the balance on acute or preventive care. For Medicare patients, it may be even higher.
This resource describes a new model that moves high-need patients out of the emergency department and into a network of social supports. Regional One Health, a large health system in Tennessee, has...
This resource describes the Great Plains Senior Services Collaborative, an initiative to improve health and quality of life for rural seniors. Populations of rural seniors face significant challenges...
New flexibility for Medicare Advantage (MA) program represents a major turning point in Medicare policy and an opportunity for health insurers and providers to work together in new and more productive ways.
Transitional care programs — where a multidisciplinary team comprehensively assesses a patient’s medical and psychosocial needs, addresses modifiable barriers, and links them to primary care — can help address critical gaps in care for people with complex needs moving between locations of care, such as from hospital to home. These programs vary widely, both in terms of what services they provide, and whether services are delivered before hospital discharge, after discharge, or as part of a “bridging” intervention with both pre- and post-discharge components. A comparative effectiveness trial...