Complex Care Organizations Shift Programs in Response to Pandemic
Organizations that help meet the complex care needs of patients have relied on strong community care ecosystems and their capability to innovate during the pandemic. For example, the annual report of the New Jersey-based Camden Coalition of Healthcare Providers details how COVID-19 tested its partnerships and shaped its future direction.
The organization’s basic model involves using its health information exchange to identify patients with complex health and social needs, meeting them in the hospital or the community, and then providing home- and community-based care management and coordination to help them meet their own goals for health and well-being. Nearly every one of its programs had to shift in some way in response to the pandemic, the report said.
In her introduction to the 2020 annual report, Camden Coalition CEO Kathleen Noonan noted that in January 2020 the organization had just released the results of a randomized controlled trial that investigated the effect of its core model on hospital readmissions. The main takeaway from that study was that no single program or organization can solve the complex care needs of its patients alone, she noted. Success in complex care relies on communities coming together to bridge systems and form coordinated ecosystems of services.
“We had no idea when we shared our analysis of the study results, or when we released our 2019 annual report, “Building strong ecosystems,” just how critical strong ecosystems of care would be in 2020,” Noonan wrote. “The COVID-19 pandemic has put all of our systems and partnerships to the test. Our failure as a country to invest in strong ecosystems of care has meant that people with complex health and social needs have been disproportionately affected by not only the virus itself, but also by the havoc it has wreaked on the systems they rely on to access healthcare, food, transportation, and housing.”
The report highlights the multitude of ways that the Camden Coalition worked with partners to meet the needs of vulnerable populations impacted by the pandemic:
• It partnered with Camden County to provide medical oversight of individuals in quarantine at a designated hotel being managed and run on the ground by Volunteers of America-Delaware Valley (VOA-DV). Camden County’s quarantine hotel, like others across the country, was designed to provide shelter and care management for COVID-positive individuals experiencing homelessness or otherwise unable to self-isolate. In addition to their COVID-19 diagnosis and lack of housing, most quarantine hotel residents had complex needs including multiple chronic medical conditions, substance use disorders, and mental health conditions. In many instances, their quarantine stays gave Camden Coalition the opportunity to support case managers from VOA-DV in connecting hotel residents to services and supports that could improve their health and well-being post-discharge.
• Camden Coalition joined a number of local healthcare organizations to support the Camden County Department of Health in opening COVID-19 testing sites in Camden. It ensured that anyone receiving a COVID-19 test was screened for any social support they might need, particularly if they were required to self-isolate. It found widespread food insecurity among those being tested, and helped connect individuals to food assistance and other resources. In late 2020, it teamed up again with Camden County and Cooper University Healthcare to roll out a mobile testing plan. It provided the data infrastructure to identify site locations, prioritizing local hotspots with high rates of COVID-19 cases. The new mobile sites are located in public schools and immediately increased access to testing for city residents.
• Two care management partnerships in 2020 helped the organization explore new ways to identify and enroll patients with complex needs. In 2019, it launched a shelter-based pilot program in partnership with VOA-DV, enrolling 38 individuals from VOA-DV’s men’s shelter in Camden into its core model and working with VOA-DV staff to coordinate participants’ care. Shelter staff were given access to the Camden Coalition HIE to identify residents eligible for the pilot program and to better coordinate their care. When COVID-19 made it impossible for staff to visit the shelter, the Camden Coalition provided the shelter with iPads to hold Zoom meetings weekly with enrolled residents, and held weekly case conference calls with the shelter staff. The pilot program ended in August 2020. Camden Coalition also began a partnership with Horizon Blue Cross Blue Shield New Jersey on a new model called Neighbors in Health, which launched in November 2020.
• The Camden Coalition is one of 29 sites participating in the Center for Medicare and Medicaid Innovation’s Accountable Health Communities (AHC) Model. It is working with practices in Camden, Burlington, and Gloucester counties, training their staff to screen patients for health-related social needs and to navigate patients to the appropriate services. During the COVID-19 pandemic, rising unemployment made social needs more acute for many in South Jersey, and self-isolation to avoid infection or transmission made it harder to fulfill basic needs and to access services. Camden Coalition’s AHC team shifted from in-person screening at many sites to a telephonic model, hired and cross-trained new screening and navigation staff, facilitated partnerships between the county health department, healthcare practices, and local social service organizations, and received grants to provide food and transportation assistance to individuals in nee
• To learn more about the level of vaccine hesitancy in the Camden community, the organization worked with its Community Advisory Committee to design an interview-style survey that asked about routine vaccinations such as the flu shot as well as the new COVID vaccines. They then worked with six partner organizations to train interviewers to administer the survey to their patients, clients, or community members. Analysis of the 265 completed surveys showed that confidence in the COVID vaccine in Camden was lower than national averages, and also generally lower than confidence in the flu vaccine. Respondents flagged a need for better education on how the COVID vaccines work and were developed, and also overwhelmingly cited medical providers as their most trusted source of information on vaccines. In 2021, the organization will share the survey results with local providers and partner organizations, and will also use the findings to inform the work of vaccine ambassadors, trusted community leaders who have been working since the fall of 2020 to educate and inform their neighbors about the benefits of getting a COVID vaccine. They will also survey Camden providers on whether and how they are discussing the COVID vaccine with their patients.
• Camden Coalition worked with its HIE vendor, CareEvolution, to make sure the HIE was providing the information the region needed: It built a shared workflow in the HIE that the organization and its partners could use to support the region’s quarantine hotel, made COVID-19 results from local testing sites available in real time to all providers, and created dashboards that integrate clinical and demographic data to give broader insight into how COVID-19 is affecting New Jersey. It also worked with the Camden County Department of Health to use it HIE to support their workflows. It also added data integration with two long-term care organizations.
• In 2020, Camden Coalition began working with Kaiser Permanente’s Institute for Health Policy to learn more about how complex care programs can use patient-reported outcome measures (PROMs) o capture patients’ perspectives on their health and well-being. It will publish a brief report in 2021 that will provide guidelines and tools for complex care providers and researchers to use PROMs in their work flow.
Noonan noted that in addition to the COVID response, Camden Coalition made major strides in advancing complex care as a unified field of practice. “We released a standardized set of core competencies for frontline complex care providers, took first steps toward standardizing quality measures for research and evaluation, and launched a “consumer voices bureau” to link organizations across the country to leaders with lived experience of complex health and social needs,” she wrote. “In 2020 we learned that it truly does take an ecosystem. We could not have done any of this without the support of our funders and the dedication of our partners, both long-time and new, in Camden and the surrounding region, in New Jersey, and across the country.”
