The practice of complex care requires significantly different knowledge, skills, and attitudes than traditional practice, and proper training and support for the complex care workforce is a significant need for the field. While there is growing awareness of some of the major competencies (e.g., trauma-informed care) that differentiate and are foundational to complex care, there has been no effort until now to name and define a comprehensive set of complex care core competencies.
Developing core competencies for front-line complex care providers and practical tools to support their use is the first recommendation of the 11 recommendations laid out in the Blueprint for Complex Care. Core competencies will enable the development of standards of practice that can be quantified, trained, and measured.
In 2019, the Complex Care Field Coordinating Committee chartered a working group made up of experts from diverse backgrounds and sectors, including complex care consumers, tasked with developing a proposed set of core competencies for the field.
Draft core competencies
We are thrilled to introduce the draft version of the complex care core competencies developed by the core competencies working group. The working group will incorporate feedback from the field into a final set of core competencies that will be released in October 2020. Survey closed 6/18/20.
These core competencies aim to capture the knowledge, skills, and attitudes needed by front-line providers across disciplines, including community health workers, social workers, physicians, nurses, and more, who care for individuals with complex health and social needs.
Any questions or feedback should be directed to Rebecca Koppel, Program Manager for Field Building and Resources, at firstname.lastname@example.org.
Learn more about the development of the draft core competencies in these reflection pieces on our blog from the Chair and Vice Chairs of the core competencies working group:
- Establishing complex care core competencies by Mark Humowiecki, General Counsel & Senior Director for National Initiatives, Camden Coalition of Healthcare Providers; Chair of the core competencies working group
- Principles for the complex care workforce: Reflections on developing core competencies by Sara Reid, Consumer Board Member, Boston Healthcare for the Homeless; Lived Experience Vice Chair
- Training the complex care workforce: Reflections on developing core competencies by Anna Doubeni, Associate Professor of Clinical Family Medicine and Community Health, University of Pennsylvania, Perelman School of Medicine; Education Vice Chair
Working group members
- Mark Humowiecki, Chair, General Counsel & Senior Director for National Initiatives, Camden Coalition of Healthcare Providers
- Anna Rebecca Boorse Doubeni, Education Vice Chair, Associate Professor of Clinical Family Medicine and Community Health, University of Pennsylvania, Perelman School of Medicine
- Sara Reid, Lived Experience Vice Chair, Consumer Board Member, Boston Healthcare for the Homeless
- Anne Whitman, Senior Community Researcher, Center for Excellence for Psychosocial and Systemic Research MGH
- Barbara Crider, JD, Executive Director, York County Community Action
- Cheryl Garrels, Community Health Worker, MercyOne Centerville Medical Clinic
- Farhad Modarai, DO, Associate Regional Medical Officer, CareMore Health – North Carolina
- Janice Tufte, Patient Partner, Hassanah Consulting
- Jodie Sevier, Community Health Worker, Clinically Integrated Network- ACO- Des Moines Chapter
- Jonathan K. Weedman, CCTP, LPC, Vice President, Population Health, CareOregon
- Lesly Starling, BA, BSN, RN, Complex Care Navigator, Kalispell Regional Healthcare
- Marsha Johnson, Managing Principal, Health Management Associates
- Martha Chavis, Executive Director, Camden Area Health Education Center (AHEC)
- Regina Danielson DNP, MAT, RN, Complex Care Research Nurse, Kaiser Permanente Mid-Atlantic Research Institute
- Scune T. Carrington, Director, Integrated Care, Massachusetts League of Community Health Centers
- Tina R. Sadarangani, Assistant Professor, New York University Rory Meyers College of Nursing
Working group member bios
Mark Humowiecki (Chair) leads the National Center for Complex Health and Social Needs, a new initiative of the Coalition that seeks to coalesce a new field of healthcare and build a national movement to improve outcomes for individuals with the most complex needs. Previously Mark led the Coalition’s advocacy, communications, and governance efforts. Before joining the Coalition, Mark served as deputy executive director of the New York State Workers’ Compensation Board and spent six years practicing employment and civil rights law. Mark earned his bachelors and law degrees from Yale University.
Dr. Anna Doubeni (Education Vice Chair) started her medical career as a student at Temple University School of Medicine in Philadelphia, PA. After training in family medicine at Duke University she completed her National Health service in rural North Carolina while starting her MPH after realizing she needed further training in community-based behavior change. Later she moved to the University of Massachusetts to complete a preventive medicine residency and continued her community based work through home visits and advocating for access to care for intellectually disabled patients.
Coming full circle, she returned to Philadelphia, now working at Penn Medicine. Her primary focus is in access to care for vulnerable populations, specifically home bound patients, patients with mental health disorders or cognitive impairment, and populations in resource-limited environments.
Consistent with that, her clinical practice and teaching are centered on patients with complex needs, including those who are homebound. In addition, she is currently the medical director for Penn Medicine Home Health, the co-medical director of Penn Partners in Care (a primary care service line care management program), the director of population health management for family medicine, and volunteers with the American Academy of Family Physicians Foundation in ongoing efforts to support family medicine training in Haiti.
Sara Reid (Lived Experience Vice Chair) has a BA Degree and is a Board Member at Boston Healthcare For The Homeless in Boston. She is chair person on the CAB and sits on several sub committees. Sara is a Transgender Health Advocate, Navigator, Consultant and Educator. She has over 40 years work experience in manufacturing, retail, childcare, social work, and customer service. Sara is proud parent of a Son and Daughter and Grandmother of 4 young grandchildren.
Anne Whitman has over 30 years of experience in starting, supporting, and guiding peer communities in providing mutual support while maintaining the core values of empathy and resiliency. Anne is someone with lived experience with mental health challenges/substance misuse and is a certified peer specialist. She is a co-founder of the Metro Boston Recovery Learning Community located at Boston Medical Center and the Cole Resource Center located at Mclean Hospital, She is a senior community researcher for the Center for Psychosocial and Systemic Research at Massachusetts General Hospital. She holds a PH.D and MA in Anthropology from Harvard University, an M.S in education and a BA in Anthropology from the University of Pennsylvania and an M.B.A from Boston University. She has held significant academic, administrative and outreach positions at Harvard, MIT, and Wheaton College. She is also a co-founder of Bright Horizons Work Family Solutions. With her diverse background in building innovative organizations combined significant leadership in peer, family and research communities, she hopes to contribute to the development of the Core Competencies for Complex Needs Project.
Barbara Crider, JD, has an extensive history of involvement with the nonprofit sector of Maine, and with York County Community Action Corporation. Barbara began with YCCAC in 1987 as the Director of Community Services, and later served as the Housing and Economic Development Consultant. Barbara left YCCAC to attend law school, and spent nearly 15 years practicing law before returning to YCCAC as Executive Director in 2010. Barbara founded and directed the Penquis Law Project, through which she provided legal counsel and representation primarily to victims of domestic violence. A recipient of the Jefferson Award for Outstanding Public Service and the Robert M. Howes Visionary Award, Ms. Crider has spent her career as an advocate for disadvantaged populations. Ms. Crider has served on the Board of Directors of the Maine Primary Care Association for a number of years. She is a member of several associations, including the American Health Lawyers Association and the Maine Community Action Association.
Cheryl Garrels is a Community Health Worker (CHW) for MercyOne Centerville Medical Clinic, a primary care clinic in rural Iowa. Cheryl has worked for MercyOne since 2017 and, along with Jodie Sevier, participated in developing the pilot CHW program, screening for social determinants of health in the primary care setting. Cheryl partners with patients to identify and navigate community resources. Through MercyOne’s ACO, Cheryl participated in Health Lead’s “Collaborative to Advance Social Health Integration” (CASHI), a cohort of twenty-one primary care teams and community partners across the US, strengthening and spreading their CHW programs. Cheryl’s previous work as a Case Manager for Milestones Area Agency on Aging gave her the privilege of coordinating in-home services for the frail elderly in her community, allowing them to continue living at home. Cheryl’s time as a Case Manager cemented her passion for assisting vulnerable populations reduce their life stressors so they can focus on improving their overall health. Cheryl’s education includes a BA, Major in Psychology/Minor in Sociology, from the University of West Georgia and a Certificate in Aging from Boston University. She is currently enrolled in the Master of Public Administration program at Capella University. Cheryl’s career goals include using her education, compassion, and innovation to highlight the importance of patient-centered care, advocate for underserved populations, and remove barriers to health care, especially in rural communities.
Farhad Modarai, DO, is a board certified family medicine physician, with working experiences in government, academic, insurance and community healthcare settings. He completed his Family Medicine training at Duke University, and fellowship training in Applied Epidemiology at the Centers for Disease Control and Prevention. In 2016, he joined a team in Memphis, TN with CareMore Health, an integrated health plan and care delivery system for Medicare and Medicaid patients. In Memphis, he was part of a collaborative and innovative team with the mission of designing and delivering comprehensive value based primary care for a medically and socially complex population. In 2019, Dr. Modarai transitioned to North Carolina to help launch and lead CareMore’s efforts in providing services to Medicaid beneficiaries under the state’s new transition to managed care.
Janice Tufte is a Patient Partner actively engaged with healthcare culture change implementation through her involvement with a number of projects and strategic initiatives. Janice has founded six local projects that incorporate social need awareness coupled with small community based solutions. She is involved with quality improvement and evidence based work, measurement and guidelines as well as serving on multiple local and national advisory groups to help affect positive informed patient centered change. www.janicetufte.com @Hassanah2017
Jodie Sevier comes to the Core Competencies Working Group with personal and professional expertise in complex care. Jodie has held various social service and philanthropy positions during her career. Currently she works for MercyOne Des Moines Medical center as a community health worker in a primary care clinic. She supports universal screening for health-related social needs and is responsible for follow-up with patients who identify a need and request assistance. In her most important role, Jodie has the lived experience of raising a child with special needs. She has navigated the health and social service systems for her family and uses that experience freely to build rapport with patients and to partner with them for resource navigation.
Jonathan Weedman, LPC, CCTP is the Vice President of Population Health at CareOregon. He is a Licensed Professional Counselor and Certified Clinical Trauma Professional. Jonathan received his BA in Psychology from Lewis-Clark College in Lewiston Idaho and his MA in Counseling Psychology from Lewis and Clark College in Portland Oregon. He is a previous adjunct instructor at Portland State University and Lewis and Clark College. Jonathan has worked across the life-span and with a variety of populations including secured residential treatment settings, intensive case management, outpatient mental health, school settings and in private practice. He is extremely passionate about spreading the knowledge of Trauma Informed Care to help improve our community response to the epidemic of trauma and reduce the transmission of Adverse Childhood Experiences (ACE).
Lesly Starling, BA, BSN is a RN Complex Care Navigator who currently partners with community health workers in a health system and community collaborative of complex care management in rural Montana; building trust with high need, high cost patients to improve communications among stakeholders in the patient’s life and medical care. Her role helping patients and their caregivers break down barriers to care, thus becoming more self-sufficient in serving their own needs , has received national attention in the media and has resulted in multiple speaking events at CMS, Vizient and ACMA. Prior to her position as a Complex Care Navigator, Lesly served in a variety of nursing roles in her capacity as an RN. This background has provided her with opportunities for leadership roles including Chair of the Northwest Montana Care Transitions Coalition,and nursing preceptor in complex care for senior level students. She was recently awarded the Patient Centered Outcomes Research Institute’s Engagement Award as Project Lead for “Building Capacity to Break Down Barriers to Complex Care Navigation in Rural America.”
Marsha Johnson is passionate about building a resilient workforce and fostering resilient systems to deliver quality, comprehensive care to individuals with complex health and social needs. Marsha has over a decade of experience in direct care at a federally-qualified health center where she developed an integrated behavioral health program. As a member of the innovation team at the Advanced Care Center at Cooper University Health, she led a range of clinical redesign efforts to improve care transitions, integrate coaching and care management into primary care and facilitate collaborative care planning with community-based services. As Chief Learning Officer at the Camden Coalition of Healthcare Providers, she provided technical assistance in complex care programming, designed curricula for students of the health professions and developed a supervision and coaching model for supervisors of direct care providers. Currently, Marsha assists states, care delivery providers and leaders with the development of data-driven, person-centered and responsive systems of care as a consultant with Health Management Associates.
Martha Chavis, MA, Executive Director of Camden Area Health Education Center (AHEC), has over 40 years of work experience with nonprofit organizations providing health education, employment and social services. A native of Philadelphia, Ms. Chavis graduated from Beaver College (now known as Arcadia University) with a B.A. in psychology and education, Temple University with an MA in Developmental Psychology and taught as an adjunct faculty in the Department for 10 years. Ms. Chavis is also a long-time (45 years) Adjunct Professor in Behavioral Sciences at Community College of Philadelphia. In her role as Director of Camden AHEC’s Community Health Worker Institute (CHWI), Ms. Chavis has worked to enhance the goals of the Institute to: increase the recognition and respect for CHWs, establish a meaningful CHW labor market and provide skills standards and accessible CHW training resources. As one of the originators and master trainers of Camden AHEC’s CHW curriculum, Ms. Chavis has also been instrumental in updating the curriculum’s basic content with workforce and community-based competencies for the CHW to demonstrate in an on-the-job training setting. Ms. Chavis is a passionate proponent for ‘a healthy quality of life’ which she believes everyone is deserving. Ms. Chavis is a resident of Camden City where she has worked for the last 35 years. Ms. Chavis believes service with human dignity is the best approach for achieving outcomes in the community that make a difference.
Regina Danielson currently serves as a Clinical Research Nurse in the Complex Care Program with Mid-Atlantic Permanente Medical Group. In this capacity, she coordinates care for patients with complex health issues, conducts research with patients, and provides education for disease management. She also works for Stratford University as an Adjunct Professor in Nursing Research and Community Health.
Prior to joining Kaiser Permanente Mid-Atlantic, Regina worked at University of Maryland Hospital as a Clinical Nurse in the Cardiac Intensive Care Unit. She also worked for Kaiser Permanente Mid-Atlantic States Health Plan as Lead Clinical Nurse in Internal Medicine.
She has a Bachelor of Arts degree in Biology from the College of Charleston, a Bachelor of Science degree in Nursing from the University of Maryland, a Master of Arts in Teaching Secondary Science Education degree from Trinity University, and a Doctor of Nursing Practice in Nursing Administration, Health Policy and Leadership from George Mason University.
Scune Carrington is currently the Director of Integrated Care for Behavioral Health and Oral Health at the Massachusetts League of Community Health Centers. In that role she is responsible for providing leadership and management of Oral Health, Behavioral Health, and Integrated Care Initiatives and practices in health centers across the state by developing technical assistance, capacity building of programs based on proven quality and process improvement models. Prior to working at the League, Scune was the Director of the Behavioral Health Community Partner Program (BHCP) in the Ambulatory and Integrated Services division of Beth Israel Lahey Health Behavioral Services. Scune also served as the Project Director of the Lahey Transformative Research and Innovation Initiative (LTRII). She has over a decade of experience in the successful implementation, execution and management behavioral health care redesign initiatives. She has extensive knowledge of behavioral health care Innovation with a passion to transform healthcare using technology to drive more efficient, safe and client-centered care. Scune has a strong professional interest in providing innovative complex care that goes beyond the traditional top-down, provider-centered care whose scope is limited by a narrow biomedical understanding of disease, to a model of care informed by the client and an understanding of disease as a result of social and psychological as well as biomedical factors, recognizing the importance of empathic connection with client and a mutually determined treatment plan. The various programs that she has managed are heavy on personal interaction with care teams, who also provide a broad range of support from helping client navigate how best to obtain housing to how to negotiate the complicated medical system, and providing transportation. At the same time, in her role with L-TRII, she has worked with the multidisciplinary advisory council to help contemplate complex care using rapidly-evolving technologies and the extent to which the personal contact and empathic understanding embedded in various program model is replaceable; and to the extent it is not, can such a connection with clients be maintained through different, more efficient means. She has co-authored “ A Framework for Complex Care Innovation, A set of aligning principles for creating change in Massachusetts complex care practice” as an output to that work. Scune is a graduate of the University of Massachusetts at Amherst and received her Master’s degree in social work from Boston College School of Social Work where she was the recipient of the Dean’s leadership award. Scune Carrington is currently pursuing her Doctorate of Health Science with a focus on Global Health at the Massachusetts College of Pharmacy and Health Sciences.
Tina Sadarangani is an Assistant Professor in the NYU Rory Meyers College of Nursing focused on improving health outcomes for ethnically diverse older adults with multimorbidity in community-based settings. Her research specifically explores the capacity of adult day care centers to integrate health and social services and improve outcomes for low-income aging immigrants.She is an expert in the use of community based participatory research methods to enhance stakeholder engagement in the research process and maintains strong community partnerships across the country. She is a Fellow of the Hartford Institute of Geriatric Nursing and an Aging Incubator Senior Fellow. Dr. Sadarangani is also a board-certified adult/gerontological primary care nurse practitioner with experience in primary care and specialty settings. In addition to her PhD from NYU, she holds an MS in Nursing from the University of Pennsylvania, a BS in Nursing from NYU, and a BA in Anthropology from Georgetown University.