Medically fragile foster children are a vulnerable population who require specialized interventions in order to ensure their safety and well-being. Research indicates that medically complex children are at higher risk of maltreatment and as a result may have an increased likelihood to become involved with the child welfare system. 

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Commonwealth Care Alliance (CCA) community health workers (CHWs) are embedded in the communities where CCA members live and are key to CCA’s ability to address member needs. They have a deep understanding of community resources, maintain relationships with diverse partners, build trust with members, and open the lines of communication for our behavioral health and medical staff.

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The need for integrated care is deeply felt in the Brooklyn, New York neighborhood of East New York, which struggles with high rates of poverty, violence, psychiatric hospitalizations, and chronic disease, exacerbated by long standing racial disparities. The COVID-19 pandemic has increased the urgency of integration and pushed this work toward technology-enabled care, including teleconsultation and point-of-care testing. Integration is at the heart of the East New York Health Hub—a marriage of behavioral health and primary care, fostered by a physical and organizational partnership between the Institute for Community Living and Community Healthcare Network, an FQHC. Most clients of the Hub suffer from mental illness, and frequently have experienced trauma that impacts their ability to trust healthcare providers. 

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Through practices like motivational interviewing, harm reduction, and our participant engagement framework COACH, the Camden Coalition’s care planning process has a powerful impact on participant engagement and cross-continuum teaming, and improves patient outcomes. During this webinar, Camden Coalition’s Gladys Antelo, Renee Murray, and Victor Murray discussed traditional and non-traditional care planning, and engagement styles that are essential to providing whole-person care to individuals living with needs beyond healthcare.

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