By Amy Yuen, Staff Writer

The National Center for Complex Health and Social Needs is an initiative of the Camden Coalition of Healthcare Providers, a nonprofit organization working in Camden, NJ to innovate and test person-centered healthcare delivery models to improve patient outcomes and reduce the cost of their care. The National Center’s local roots inform its approach to working with organizations across the country that serve individuals with complex health and social needs in their own communities. In February 2018, Kathleen Noonan was announced as the new CEO of the Camden Coalition and the National Center.

Onboarding a new CEO opens up a world of possibility for community-based healthcare organizations like the Camden Coalition. Recently, the Camden Coalition’s Amy Yuen sat down with our CEO Kathleen Noonan to reflect on the first 100 days in her new role and her vision for the future.

Tell us a little about yourself.

I’ve spent the last two decades immersed in healthcare policy, operations, and delivery system reform in Pennsylvania, Wisconsin, and New York. I co-founded PolicyLab — a research center at Children’s Hospital of Philadelphia — and I have taught at the University of Pennsylvania Masters of Public Health Program and School of Medicine, and at the University of Wisconsin Law School. I currently serve as Vice President of the Board of Directors of Public Citizens for Children and Youth, a multi-issue children’s advocacy organization in Philadelphia. I started my career in government affairs for a children’s advocacy organization in New York City, and spent seven years working very closely with public agencies engaged in large-scale system reform efforts as part of a management consulting group created by the Annie E. Casey Foundation. I view strong partnerships as key ingredients to successful practice or policy change.

I got to know the Camden Coalition about six years ago when PolicyLab began working with the Coalition to fine tune its patient engagement framework and catalog the methods used to develop authentic healing relationships with patients.

For the last three and a half months, I’ve been busy listening to and learning from the Coalition’s board, staff, and partners about the essential work of the Coalition. I’ve heard firsthand the challenges of reaching more people with the Coalition’s special brand of engagement that focuses on population health and policy change. At the same time, I’ve been keeping my eyes on the future and thinking about the Coalition’s longer-term goals.

Looking back at your first 100 days, what have you learned?

From the outside, I knew the Camden Coalition as an organization that was deeply mission-driven and passionate about society’s most difficult issues, like the intersection of healthcare and criminal justice — making sure that people who were released from jail with chronic health conditions had a place to go that would help them stay out of jail and healthy enough to stay out of the hospital. I can say that 100 days in, I see these values in action every day working alongside Coalition staff, partners, and board members who are 100% committed to serving people with complex healthcare needs and to changing community conditions that create poor health and poor social outcomes. There’s no sense of hopelessness at the Camden Coalition, despite the difficult issues we work on. It’s inspiring to work with a shared purpose and so wonderful to see the Coalition live its mission every day.

I’ve also seen that the field of care management has gotten much more crowded than it was when the Coalition was founded. This really requires us to think of ourselves as an innovation group where we use data differently and test new approaches while continuing to hone our craft. We need to get smarter about where we can offer the most value and be of best use to hospital systems and cross-sector community organizations, and where we can join forces and create partnerships with other providers doing similar work.

What’s the most surprising thing you’ve found?

I don’t think it’s surprising, but it is remarkable that for all the advances in data and information technology, we still get regular requests to educate groups on the Camden Coalition’s active use of real-time data to help the patients we see every day. Each morning I arrive at the Coalition, someone from our care team is looking at live patient data from hospitals and other providers across the region to identify patients who are most in need of care coordination. I think our data management and analytics capacity adds real value for front-line providers, healthcare systems, payers and government because the industry still operates with a siloed business model, and collects a lot of data that is not used or not shared. Here at the Camden Coalition, we build and maintain data and practice bridges to work across silos.

What led you to the Camden Coalition?

The Coalition’s founder Jeff Brenner and I happened to attend the same conference, and we got to talking about work I had done with big human services systems that were trying to change how they worked with clients while also making bigger system changes. We realized that we both had a very similar approach to thinking about system improvement and change. Afterward, I was invited to the Camden Coalition to do a brown bag presentation, and that resulted in an ongoing relationship. After the presentation, I was asked to help the Coalition document its practice model. Together, we developed the Camden Coalition’s COACH manual, our much-lauded approach to working with patients in the field.

Tell me more about what attracted you to the Coalition.

At my previous position at CHOP PolicyLab, our research was grounded in issues identified through clinical work with children and families. Our interest in creating evidence-based solutions to improve health services and policy was for real patients. That’s one of the things that attracted me to the Coalition — we’ve been working actively with patients with complex needs in Camden for over 15 years, and we base our local, regional, and national policy work in that experience. There’s a lot of credibility there, and a lot of commitment that produces results for actual people. Nothing I do at the Coalition feels removed or academic. We learn and do in tandem.

What are the parallels between the patient population at CHOP and the patient population at the Coalition?

Well, first, I have to say I feel lucky to have been part of two great organizations. Both focus on health, but the Coalition’s focus is grounded more broadly on community since our work is really in the neighborhoods all around Camden and the surrounding region. CHOP approaches its patients from a family system perspective, and that’s similar to how the Coalition approaches its patients. The Camden Coalition approaches patients with complex needs in a holistic way — building on systems and community networks the patient already has in place, and then connecting them to other supports they need to help them reach their goals.

What makes this an exciting time for the complex care field?

Some of what the Coalition was talking about 10-11 years ago has finally taken hold — the concept of whole person care and the idea that you can’t just treat a disease, but you have to treat a person in the context of where they live and what they want. Today, it’s not just the Coalition and a few other organizations that have community health workers. Now, you have insurance companies incentivizing big hospital systems to do home visits and care navigation and think about what they can do outside the hospital to help patients get or stay well. This makes for more dynamic partnerships and new opportunities to grow our work in new ways.

On the other hand, there’s so much more we don’t know, especially when medical and social complexity come together in one patient. A person with chronic illness who’s homeless, or a patient with a chronic illness and acute mental health needs — there’s a lot more we need to understand about the best ways to help people with complex needs navigate the healthcare system, manage symptoms, and prevent or reduce unnecessary hospitalization. And we’re hard at work figuring out how to best address medical and social complexity in an efficient way that delivers the highest value for the people and communities we serve. There’s still a lot of waste in the system, so I think there’s also a lot to do in this regard.

What do you see as the next steps for the Camden Coalition?

I am still refining our agenda with the board and other partners, but at least five priorities seem to be emerging. The first is to maximize the value of our Health Information Exchange (HIE) for the smaller healthcare and social service providers we work with, while also making sure it continues to add value to the care coordination staff at hospitals that use it. In keeping with our role as innovator, we’ll look at how the HIE could be useful to nontraditional partners, like organizations in our Faith in Prevention initiative funded through the state Department of Health, where — for example — parishioners can opt in to letting their faith leaders get alerts if they’re admitted to the hospital. We know social isolation is real for many of the people we work with in Camden, and we’re looking for ways to connect family caregivers and other natural or community supports to them while they’re in the hospital to help them and potentially keep them from being readmitted after they’re discharged. Another example is the clinic at the Camden jail, which just this spring began sending data to the HIE, so that when its patients return to the community, their primary healthcare providers can pick up where the clinic left off.

I’d also like us to build out the Coalition’s teaching and training for the field of complex care. Now that we’ve codified our care management approach through COACH and fine-tuned how to train individuals and organizations on it, we’ll spend more time training both regionally and nationally. I also want to broaden our reach and train more community-based networks in how to use data to improve health and well-being. We’re now doing trainings all over the country, like in Boston, California, and Tennessee, and I’d like to see that expand and continue.

We should continue to push the field of complex care and the knowledge of what it takes to treat and care for patients who don’t just have medical issues, but also have very difficult social issues. That requires looking across boundaries to really help them — care coordination without walls. The Camden Coalition houses the National Center for Complex Health and Social Needs, funded through generous grants from RWJF, Atlantic Philanthropies, and AARP. This center focuses on disseminating best practices on complex care, featuring the work of our partners in Camden, as well as providers, policymakers, and public health and hospital systems nationally. On December 5th through the 7th, we’ll hold our third annual national conference in Chicago, where we expect over 600 experts to attend from almost every state in the country.

I want to continue to generate and spread knowledge from our care interventions as well as the amazing work of our partners here in Camden and our surrounding region. We’re a designated regional Accountable Care Organization by the state, and in the last year of that demonstration. The Coalition is rigorous about tracking key performance metrics on our care interventions, so I really want us to dig in and see who the interventions are working for and who they’re not working for. Are there people with certain demographics that respond better than others? Are there people with disease conditions that respond better than others? We just looked at our 7-Day Pledge data and found that there are patients who responded better than we thought they would. So even challenging our own assumptions. If we want to help people get and stay well, we need to get the word out about what’s working and what isn’t. We have several crises in our state right now related to opioids and infant mortality, among others. The uses of medical marijuana also require attention. We believe the regional ACOs can support the government’s work on these issues, perhaps evolving into some type of “Regional Health Hub” or “Collaborative” model, where we can support local, regional, and state needs through targeted care interventions and population-level data tracking and analysis. We need input from our partners on next steps for the ACO, and I am excited to do that planning work with them.

Finally, we need to do more to support primary care providers. One of the concepts that has taken hold as a result of the Affordable Care Act and other reforms is this idea that everybody needs a medical home. That’s put a lot of pressure on primary care practitioners and practices, especially in a place like Camden where many patients need a lot of support. Of all of the changes that have come from health reform, what hasn’t changed is that primary care doctors still see six patients an hour. In other words, medical appointments haven’t gotten longer, but the demands have gotten greater. We have a network of primary care providers in our city, and I want to continue to learn from them and advocate for the kinds of support they need.

At their Monday huddles, the care team always starts their week with a word for the week. What’s your word for your first 100 days at the Coalition? And for your next 100 days?

For the first 100 days, it’s been “examine” — a lot of reviewing, fact-finding, and validation. For the next 100 days, I don’t know if “solidify” is the right word, but my plan is to focus our talent, energy, and resources on the strategic initiatives I mentioned where we can make the biggest difference to the people and communities we serve.