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Healthcare on wheels: How mobile clinics meet the complex health and social needs of patients
The COVID-19 pandemic has sparked innovation in models of healthcare delivery, including new and expanded use of mobile clinics. As an important part of an integrated care team, mobile clinics can address the complex health and social needs of patients by meeting patients where they are....Read more
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The keys to financially sustaining coordinated complex care strategies
Across the country and in diverse care settings, providers have developed innovative, highly promising strategies for treating patients with complex health and social needs. Unfortunately, most healthcare systems and payment policies do not seamlessly support the necessary infrastructure and partnerships. Therefore, these strategies are difficult to sustain financially, despite evidence demonstrating cost savings and improved […]...Read more
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Valued behavioral health outcomes in complex care
The field of complex care is grappling with questions around demonstrating value: beyond cost savings, how can complex care programs prove their impact? The question of which outcomes to measure is particularly important in behavioral health. Few published evaluations of complex care programs address behavioral health outcomes, and common behavioral health outcome measures may not […]...Read more
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Lessons on consumer engagement from Amplify
Authentic consumer partnerships have the potential to build trust, foster equity and inclusion, support community health and well-being, and improve health outcomes. However, creating these authentic partnerships requires a significant change of practice from most organizations to ensure that partnerships with consumers are mutually beneficial. ...Read more
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Valued behavioral health outcomes in complex care
While behavioral health concerns are common among individuals with complex health and social needs, existing behavioral health outcome measures may not be appropriate for use in complex care programs. Fulbright Fellow from McMaster University, Cara Evans, in partnership with Jason Turi, Camden Coalition Director of Field Building & Resources, and Rebecca Sax, former Camden Coalition […]...Read more
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The Front Door Initiative: Connection, care coordination, and community collaboration
The Front Door Initiative is a grant-funded project at the Allegheny Health Network Jefferson Hospital to address needs related to social determinants of health for patients in the emergency department. In this webinar, panelists from Allegheny Health Network and Cornerstone Care shared how the Front Door Initiative’s process is helping meet the needs of their […]...Read more
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Psychological safety: A prescription for more effective teams
In the highest-performing teams, members feel safe to take interpersonal risks — to speak up, to push back, to challenge the status quo. In this webinar, Kari Mader of Aurora Wellness Community at the University of Colorado and Kyle Turner of the University of Utah College of Pharmacy discussed how teams form and evolve, and […]...Read more
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Thriving and surviving after a medical diagnosis: Strategies for patients and providers
A webinar hosted by the National Consumer Scholars For many people, receiving a serious medical diagnosis for themselves or a loved one is a turning point in life. In the moments following a diagnosis, care providers have the opportunity to ensure that their patients understand the prognosis, process complex emotions, and connect to follow-up care […]...Read more
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After incarceration: Providing team-based, recovery-focused support for people with substance use disorders leaving state prisons
In May 2022, we welcomed Micah Hillis and Corey Kuebler of Rutgers University Behavioral Health Care and Peter Treitler of Rutgers Center for Health Services Research to discuss New Jersey’s Intensive Recovery Treatment Support (IRTS) Program. This first-in-the-nation support initiative was designed to provide recovery-focused assessment of needs, linkage to treatment, and comprehensive re-entry support […]...Read more
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Optimizing outcomes for patients with chronic illnesses and disabilities
In this webinar, Dr. Matthew Weed focused on bringing awareness to the challenges patients with disabilities and chronic illnesses and their caregivers face and the importance of better understanding their needs. Dr. Weed also touched on the Americans with Disabilities Act and discussed accessibility and accommodations for patients with chronic health concerns and disabilities....Read more
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Integrating community health workers into a safety net hospital system to address health inequities
Sinai Urban Health Institute (SUHI), the community-engaged research arm of safety net hospital Sinai Chicago (Sinai), is a leader in the development, implementation, and evaluation of innovative approaches to improve population health with a primary focus on communities on the South and West Sides of Chicago. Residents of these majority Black and Latinx communities often […]...Read more
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Navigating the complex needs of youth aging out of foster care: A care management organization’s approach
Transitioning to adulthood is challenging, especially for youth in the foster care system. The roughly 50% of youth that age out of foster care without either returning to the custody of a biological parent or being adopted often lack the support they need to encourage their ongoing attention to their physical and behavioral needs. Since […]...Read more
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Rethinking value: Perspectives on the benefits of cross-sector collaboratives serving populations with complex health and social needs
Cross-sector collaboration is recognized as an important step in improving health equity and addressing the collective challenges facing healthcare, the social sector, and public health organizations at the community level. However, different sectors and community stakeholders continue to operate under siloed cultural, operational, and funding structures and contexts. We explored how different organizations and community […]...Read more
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Progress in implementing the recommendations in the Blueprint for Complex Care
Complex care is a growing field that seeks to improve health and well-being for people with complex health and social needs — those with multiple medical, behavioral health, and social needs that intersect to drive poor health and well-being outcomes. For over five years, a diverse and growing community of providers, payers, consumers, policymakers, researchers, […]...Read more
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Working with medically complex children in foster care and their caregivers
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. ...Read more
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Addressing social and behavioral health through fully integrated, interdisciplinary care teams
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 […]...Read more
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In pursuit of seamless integration: The East New York Health Hub
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 […]...Read more
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Transform your engagement practices
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 […]...Read more
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CHWs as community connectors and care team supervisors
Community health workers (CHWs) play an important role in reaching underserved populations in communities with high levels of complex social and medical needs. At Baylor Scott & White Health System (BSWHS) in Texas, CHWs have been addressing the health and social needs of the community since 2017. In that time, BSWHS has developed a workforce […]...Read more
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Building a system of care for children with complex medical and social needs
Children with medical complexities require specialized services and care delivery models across the healthcare continuum – from inpatient, outpatient, transitional, respite, home care, and community support services to physicians, nurses, and other providers with the expertise to care for these children. The care system for this population of children is extensive and fragmented, and seldom […]...Read more
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Anti-racism resource toolkit
This publication was produced by the Pennsylvania Department of Health (DOH) Office of Health Equity as part of the National Center’s 2020 regional complex care convening cohort. The publication describes “Dismantling Systemic Racism in Pennsylvania,” the DOH convening of 200 participants across 26 state agencies. It includes an extensive toolkit of books, articles, videos, podcasts, and […]...Read more
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Strengthening health & housing collaboration in Louisiana
This publication was produced by the Louisiana Public Health Institute, HousingNOLA, and Green and Healthy Homes Initiative as part of the National Center’s 2020 regional complex care convening cohort. The publication synthesizes findings from the New Orleans Healthy Homes Regional Convening focused on enhancing healthy homes interventions to demonstrate the impact of home-based interventions and […]...Read more
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Massachusetts complex care convening and learning community: Project summary July 2021
This publication was produced by The Brookline Center for Community Mental Health as part of the National Center’s 2020 regional complex care convening cohort. Their Massachusetts convening brought together a regional learning community to better navigate siloed systems to improve the care of people with complex health needs. This publication synthesizes the planning process, key […]...Read more
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Addressing social isolation and loneliness in central Iowa
This publication was produced by MercyOne Iowa as part of the National Center’s 2020 regional complex care convening cohort. MercyOne brought a cross-sector team together to plan a regional convening to better understanding of the impact of social isolation and loneliness on the health of their community and to develop a roadmap to collaboratively address […]...Read more
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Path-4CNC (Children’s Complex Care Coalition of North Carolina) Complex Care Convenings 2021: Executive summary
This publication was produced by Duke University and the University of North Carolina at Chapel Hill as part of the National Center’s 2020 regional complex care convening cohort. The publication synthesizes findings from the Path-4CNC conference series focused on improving systems of care for children with complex health needs in North Carolina. It includes actionable […]...Read more
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Building the Value Case for Complex Care Toolkit
This toolkit from the National Center for Complex Health and Social Needs was designed to be a simple and accessible way to learn about one of the least understood and most challenging aspects of complex care: making the mission and margin align. With support from The Commonwealth Fund, we interviewed more than 100 health and […]...Read more
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Compensating consumers and considerations for public benefit recipients
In this memo, Jeremy Spiegel, Esq. and Ashley Maddison, Esq. of the Rutgers Law School/Camden Coalition Medical-Legal Partnership and Evelyne Kane of the Camden Coalition of Healthcare Providers outline ways organizations can fairly compensate lived-experience experts without jeopardizing their eligibility for federal or state benefits. These include working creatively within the current legal confines for […]...Read more
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Rethinking complex care measurement: Using patient- and staff-reported measures
Complex care stakeholders across the nation are committed to finding new ways to measure quality and impact of complex care programs, ways that incorporate the holistic goals of caring for individuals with complex health and social needs. The Blueprint for Complex Care and Measuring Complexity, seminal reports in the complex care field, highlighted the need […]...Read more
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Person-centered implementation of patient-reported outcome measures (PROMS) in complex care programs
This brief from the National Center for Complex Health and Social Needs and the Kaiser Permanente Institute for Health Policy and Care Management Institute examines the factors that support or hinder the implementation of patient-reported outcome measures (PROMs) in complex care programs. The authors found that simply including PROMs in a complex care measurement strategy […]...Read more
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Breaking the homelessness-jail cycle with Housing First: Results from the Denver Supportive Housing Social Impact Bond Initiative
This report by the Urban Institute tracked and evaluated the implementation of the 2016 Denver Supportive Housing Impact Bond Initiative (Denver SIB), an initiative that provides supportive housing through a Housing First approach. This report includes the randomized-control trial and evaluation results of the efficacy of the supportive housing initiative over a five-year period. Read […]...Read more
Events & Webinars
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Recent News
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Key themes in complex care emerge from Putting Care at the Center 2022
By Hannah Mogul-Adlin, Senior Communications Manager After two years of virtual conferences due to t...
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Developing your complex care program: New tools and resources in the Startup Toolkit 2.0
By Margaux Bigelow, Program Assistant for Field Building and Resources Starting a new complex care p...
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The promise and challenge of CalAIM
Mark Humowiecki, JD, General Counsel & Senior Director A bold experiment in complex care is unde...
The National Center for Complex Health and Social Needs is an initiative of the Camden Coalition.