Does the Camden Coalition Model Work?
Some thoughts on care coordination
A new study published in Health Affairs is making the rounds online and sparking some interesting questions. It looks at the Camden Coalition, a New Jersey based care coordination model that aims to improve outcomes and utilization metrics for patients who are high-utilizers of healthcare in New Jersey. The goal is to reduce healthcare costs and hospital readmissions by coordinating care for these patients and addressing their social determinants of health, such as housing and food security. If you haven’t already read Atul Gawande’s 2011 article on the program, I highly recommend it to get an overview.
A 2020 NEJM study of an 800-person RCT showed no difference in readmission rates between patients in the Camden Coalition model versus the control group. This was a pretty radical finding because it questions the foundational principles of what the Camden Coalition set out to do. If it can’t reduce hospital readmissions for high-utilizers through better care coordination, is it worthwhile? Well, that’s a complex question.
The new study notes that the original RCT only examined readmission rates, which doesn’t reveal if care coordination (i.e. getting patients follow-up appointments post-discharge) doesn’t actually work or if there was an implementation issue due to faulty operations. In order to test this, they took the 800 participants and looked at Medicaid data to see whether or not ambulatory visits were actually done after discharge. They found that the Camden Coalition model increased post-discharge visits by 15%, suggesting that care coordination alone may be insufficient in reducing readmissions for high-utilizers with complex conditions.
That’s kind of a significant finding, especially considering many other programs targeting high-utilizers base their framework on the Camden Coalition model. However, I think there’s more to the story.
The first thing to consider is what care coordination actually is. The recent study defines it as ensuring a patient has a follow-up appointment post-discharge. However, if you’ve ever practiced medicine, you probably understand that just having a follow-up appointment (or even multiple follow-up appointments) after discharge isn’t really enough to significantly impact a patient’s health, particularly those with complex conditions.
Managing these populations requires coordinating other things like transportation, medication access and adherence, diet and nutrition, physical therapy, rehab, and housing. Social determinants significantly impact complex patients, and quick ambulatory follow-up appointments can only do so much. It’s not that surprising that this wouldn’t reduce readmissions.
This actually leads to a hypothesis that investing in wraparound services and on-the ground care teams may benefit these populations. Although hypothetical, it makes sense that for people who have complex conditions mixed with economic or social barriers, addressing the root causes is the only way to improve their health and possibly keep them out of the hospital for longer periods of time.
The other point to consider is whether this model should only be exclusive to medically complex high-utilizers. This is basically choosing the hardest population of the healthcare system to manage which makes sense given that it is also the population that costs the most to take care of.
However, including less complex high-utilizers or more complex patients with many needs but infrequent hospital admissions might offset costs associated with the Camden Coalition’s typical population. Currently, even if the Coalition’s model does everything right, one acute event could lead to a high cost hospitalization which effectively could wipe out cost savings that the program has achieved. Increasing the variability of the patient mix could reduce overall risk.
This is of course is easier said than done, but it’s crucial to understand who you’re building for and know the true needs of your target population, an obvious but frequently overlooked step.
To end with a spicy take, let’s consider whether readmission rates should even matter. Right now, the thinking is that the goal of the Camden Coalition should be to improve outcomes and reduce readmission rates for high-utilizers, based on the notion that a small group of patients accounts for a large portion of healthcare costs and that managing these patients effectively could decrease overall costs.
This adopts a capitalistic approach to healthcare and treats it like any other good in the market. However, if we view healthcare as a right that should be available to anyone and not just an economic variable then maybe it’s acceptable if a small group of complex patients with the most barriers incur more cost. We should provide services and tools to enhance their lives nonetheless. Investing in these patients will reveal more system flaws and push us toward offering sufficient care for vulnerable populations.
It’s not a take that sells well and probably not one to include in your VC pitch deck, but there is some truth to it. Maybe at the end of the day we should consider the metrics we chase versus those we should prioritize. The Camden Coalition boldly addresses this issue, and I’m hopeful their work will continue to urge us in being critical of the gaps that exist in our current system.