An evolving practice

Since 2007, our clinical team has worked in Camden to reduce preventable hospital readmissions for some of the city’s most vulnerable residents.

Our practice has evolved – we are always learning from our patients, from their families and friends, and from each other.

Over time, the core principles of care needed to work successfully with frequent utilizers of the system have emerged. Super-utilizers are some of the most difficult and complex patients in the health care system, and the standard model of care has been proven to fail them over and over.

Enable genuine healing relationships

Our care is grounded in acceptance. We believe that by meeting our patients where they are, without judgment or preconceptions, and understanding and respecting who they are, we enable genuine healing relationships that can lead to meaningful change.

Four key principles

Our interventions are guided by four key principles of care:

+ motivational interviewingA conversational technique that engages a patient’s motivation to change based on his or her own needs and wants rather than a provider’s goals.
+ trauma-informed careA framework for care that realizes the prevalence of trauma in a population, recognizes the presence of trauma symptoms in an individual, acknowledges the role that trauma has played in a patient’s life, and seeks to avoid re-traumatization.
+ accompanimentThe principle that care coordinators should be active but short-term participants in health care provider visits and other interactions, with the goal of helping develop the patient’s capacity for self-advocacy and independent navigation of complex systems.
+ harm reductionA set of practical strategies and ideas aimed at reducing negative consequences of various human behaviors, legal and illegal, especially those associated with drug use.

Borrowed from the language of behavioral health, these principles form the foundation of working with the systems’ most challenging, costly patients and empowering them to create a culture of health in their own lives.