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Study: Camden Coalition’s Complex Care Model Improves Access to Primary Care, Specialists, and Durable Medical Equipment

This new study demonstrates how our care coordination model successfully connects vulnerable individuals to ongoing care.”
— Kathleen Noonan, Camden Coalition CEO.
CAMDEN, NJ, UNITED STATES, January 8, 2024 / -- A new study shows that the Camden Coalition’s care management intervention led to a 56% increase in the number of Medicaid beneficiaries who received follow-up care from primary care providers or specialists within 14 days of a hospitalization. The number of patients who obtained durable medical equipment such as oxygen supplies and wheelchairs during this vulnerable period also increased by almost 42%.

The study, newly published in Health Affairs ( by researchers affiliated with the Abdul Latif Jameel Poverty Action Lab (J-PAL), Rutgers Center for State Health Policy, and the Camden Coalition, is an update of the 2020 randomized controlled trial of the Camden Coalition’s’ complex care model. Among its findings:

- 27.1 percent of the control group had an ambulatory visit within 14 days of discharge. The program increased this probability by 15.3 percentage points, a 56.5 percent relative increase.

- The program increased the proportion of individuals who had received any durable medical equipment 180 days after discharge by 12.4 percentage points, a 42 percent increase relative to the control mean.

“These results are confirmation that our efforts to connect patients with complex needs to outpatient care and other supports are working,” said Camden Coalition CEO Kathleen Noonan. “And yet, so much remains to be done.”

“Building a bridge to outpatient care for people living in extreme poverty and those stigmatized by serious mental illnesses and substance use disorders is not a small undertaking,” Noonan continued. “Many of our clients lack access to stable housing, transportation, and jobs with livable wages that are foundational to health.”

While the original study in 2020 reported that hospitalizations within six months were similar for the intervention and control groups, a subsequent distillation of those results found a sharply lower readmission rate for patients who were most likely to engage with Camden Coalition teams.

Since that original study was done, the Camden Coalition has launched several programs aimed at engaging more patients and building a more effective complex care ecosystem. Its Medical Legal Partnership (MLP) with Rutgers Law School embeds attorneys on site into the care teams at health services sites to help participants resolve legal matters as soon as possible. Its Pledge to Connect program, now across four regional health systems and two certified community behavioral health centers, embeds behavioral health navigators into Emergency Departments to provide timely, in-person support to connect people being discharged from the ED with community-based mental health treatment.

Camden Coalition also led the effort in New Jersey to create – and is one of the first – Regional Health Hubs (RHH), serving as intermediaries between the state government, Medicaid recipients, and the organizations that serve members of the community members. This model was recently highlighted in the White House’s “US Playbook to Address Social Determinants of Health.” It has also launched training programs through its National Center for Complex Health and Social Needs, including a new Complex Care Certificate aimed at strengthening the practice of complex care across the country.

Also, since every individual has different goals, the organization is exploring more effective methods of measuring the impact of its programs on participants’ quality of life. An example is the Person-Centered Outcome Measures, a pilot program it is piloting through a learning collaborative convened by the National Committee for Quality Assurance (NCQA).

“This new study demonstrates how our care coordination model successfully connects vulnerable individuals to ongoing care. We will continue to test and measure our work, and hope to see better outcomes as organizations, systems, agencies, and residents work together to build a more robust and coordinated ecosystem of care,” Noonan said.

Op-ed in Health Affairs by Kathleen Noonan:
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About the Camden Coalition
The Camden Coalition works to improve care for people with complex health and social needs in Camden, NJ, and across the country. The organization implements person-centered programs and pilots new models that address chronic illness and social barriers to health and well-being. Supported by a robust data infrastructure, cross-sector convening, and shared learning, its community-based programs improve outcomes for some of society’s most vulnerable individuals. The Camden Coalition’s National Center for Complex Health and Social Needs (National Center) connects complex care practitioners with each other and with data, tools, and other resources. For more information, visit

Teri Willard
Camden Coalition
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