New research in JAMA Network Open underscores the significance of patient engagement in care coordination and social determinants of health (SDOH) interventions. By studying the Camden Core Model, researchers found that patients actively participating in such interventions experienced significantly lower readmission rates. The study identifies which patients are more likely to engage, offering valuable insights for similar healthcare initiatives. Patients facing housing instability or a history of criminal justice involvement were less engaged, suggesting the need for tailored strategies to address their unique needs.
New research published in JAMA Network Open emphasizes the critical importance of patient engagement and activation in the realm of care coordination and interventions related to social determinants of health (SDOH). This study, conducted by researchers from the Camden Coalition in New Jersey and Kaiser Permanente in California, underscores the significance of key principles in value-based care. Specifically, it highlights that when hospitals effectively coordinate post-discharge access to social services and manage care for patients with complex social needs, and when patients actively participate in these interventions, the organization can achieve better outcomes, including reduced hospital readmission rates.
This study serves as a follow-up to a 2020 report that challenged the traditional value proposition of value-based care, which posited that care coordination and addressing SDOH could improve outcomes for socially complex patients. The 2020 study, published in the New England Journal of Medicine, featured the Camden Coalition’s Camden Core Model, where the organization identifies high-risk patients for post-discharge care coordination.
The Camden Core Model hypothesized that by addressing both social and clinical needs through coordinated interventions, there would be downstream benefits, such as improved readmission rates. However, the 2020 study did not confirm this hypothesis; readmission rates remained largely unchanged between the intervention group and the control group receiving standard care.
The latest study delves deeper into the performance of the Camden Core Model among different subgroups within the intervention group. Using data on intervention participation, the researchers categorized patients based on their level of engagement or activation. Subsequently, they examined readmission rates within these subgroups.
According to the researchers, segmenting the intervention group in this manner provided valuable insights into the effectiveness of care coordination and the Camden Model of Care.
Dawn Wiest, one of the study’s authors, explained, “By analyzing the data in this way, we were able to discern significant differences in readmission rates and counts between patients in the intervention group and those in the control group. Notably, those who were more engaged in the intervention experienced significantly better outcomes.”
Patients identified as more engaged exhibited superior outcomes. The relative risk of 30-day hospital readmission among these highly engaged subgroups was 48 percent lower than that of less engaged subgroups. Moreover, the relative risk of 90-day readmission was reduced by 52 percent.
While these findings may not be entirely unexpected, they contribute a nuanced perspective to the broader value proposition of value-based care.
Kathleen Noonan, CEO of the Camden Coalition, expressed her satisfaction with the results, saying, “We now have data supporting the effectiveness of the Camden Model, which is benefiting individuals with complex medical and social needs not only in our community but around the country. By demonstrating the association between our care management model, the frequency of engagement, and hospital readmissions, we can build a better roadmap for how to improve our overall complex care ecosystem—so that we can provide resources that keep patients engaged and on the path toward a better life.”
This data isn’t just a victory for the Camden Coalition and nationwide care coordination efforts. The researchers also identified which patients were most likely to engage in care coordination and SDOH interventions. This insight could serve as a valuable guide for other organizations engaged in similar work.
Specifically, the research revealed that patients facing housing instability or with a history of involvement with the criminal justice system were less likely to engage with the Camden Model of Care. The team suggested that this might be due to the challenges in maintaining contact with these particular patients.
As a recommendation, healthcare organizations may consider revising program inclusion criteria to target populations more inclined to engage with and benefit from care coordination interventions. Additionally, exploring partnerships with social services tailored for individuals dealing with housing insecurity or a history of involvement with the criminal justice system could effectively address this fundamental need.
