Care Coordination Model Increases Primary Care Follow-Up Access

The Camden Coalition’s model for care management and care coordination may not have achieved its initial aims of reducing hospital readmissions, but the program was successful in improving patient access to follow-up care with primary care providers and specialists, the organization reported in Health Affairs.

The study, published ahead of print at the end of last year, showed a 15-percentage point increase in ambulatory follow-up as the result of Camden Coalition’s care management program, plus a 12.4-percentage point increase in access to durable medical equipment, like wheelchairs or oxygen supplies.

“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 in an emailed press release. “And yet, so much remains to be done.”

This study follows up on 2020 data disproving Camden Coalition’s initial goals for its care management model—reduced hospital readmissions. The randomized controlled trial (RCT), which included nearly 800 patients, examined how Camden Coalition’s Camden Core Model could create cost savings by managing the care for the most vulnerable 0.5 percent of Camden, New Jersey, who rack up some 11 percent of hospital expenditures.

“The program provides a high-touch, face-to-face model of care designed to engage patients and connect them to appropriate medical care, existing governmental benefits, and community-based services,” researchers wrote in this most recent Health Affairs report. “Its goal is to break the cycle of repeat hospitalizations, improve patients’ wellbeing, and reduce health care costs.”

Since then, Camden Coalition researchers have looked into explanations for the lack of results.

This newest study looked at how the Camden Coalition’s care management model impacted other types of healthcare access and utilization, such as post-discharge ambulatory care, which the team said is a key indicator of good care coordination.

Using Medicaid data linked to patients included in the initial 2020 analysis, the team was able to identify an increase in patient access to follow-up care and access to durable medical equipment. In particular, the Camden model of care increased ambulatory care access by 15 percentage points after 14 days, driven mostly by access to primary care providers. The team added that this persisted through 365 days. This all amounts to a relative 56.5 percent increase.

The model of care also increased access to durable medical equipment within 180 days, marking a 12-percentage point increase, or a relative 42 percent increase, compared to a control group.

These findings follow a report from September 2023 finding that Camden’s program does cut hospital readmissions when focusing on patients with higher activation. The relative 30-day hospital readmission risk among the more engaged patients was 48 percent lower than for the less engaged patients. Meanwhile, the relative 90-day readmission risk was 52 percent lower, researchers wrote in JAMA Network Open.

Combined, these studies have been instrumental not just in giving credence to Camden Coalition’s model of care, but to making improvements to the model.

“This new study demonstrates how our care coordination model successfully connects vulnerable individuals to ongoing care,” Noonan explained. “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.”

Although the Health Affairs study looks at data from the original 2020 RCT, Camden Coalition has zeroed in on some updates to the program since, the organization said in the press release.

“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 added. “Many of our clients lack access to stable housing, transportation, and jobs with livable wages that are foundational to health.”

Camden Coalition is home to a medical-legal partnership with Rutgers Law School, and its Pledge to Connect program places behavioral health navigators in the emergency department to ensure access to community-based mental healthcare.

Camden Coalition also said it will move forward by looking into different quality of life measures, including the Person-Centered Outcome Measure in pilot phases with the National Committee for Quality Assurance (NCQA).