Camden Coalition of Healthcare Providers

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Integrated Diabetes Care Program

Location: Camden, New Jersey

The Camden Coalition of Healthcare Providers (The Coalition) aimed to improve the quality, capacity, and accessibility of healthcare for vulnerable populations in Camden, New Jersey. The Coalition established the Camden Citywide Diabetes Collaborative to improve diabetes care at the patient, practice, and community levels, and the Integrated Diabetes Care Program to provide coordinated diabetes care for patients with the highest healthcare utilization. Using a team of nurses, Community Health Workers, practice coaches, and other specialists, the Coalition sought to strengthen diabetes care directly through care management for the most complex patients, in primary care offices, and in classes for diabetes self-management.


In an effort to address disparities related to diabetes, the Coalition addressed three goals: 1) Enhance the capacity of primary care provider practices to provide evidence-based diabetes care; 2) Improve access to diabetes self-management activities for Camden residents citywide; and 3) Empower Camden residents with diabetes to reach optimal diabetes control through innovative care management strategies. Staff at the Coalition believe that if they could provide the small percentage of “super-users”— those who have multiple inpatient admissions related to diabetes as well as behavioral health issues and social barriers to health —with better, more coordinated care that addressed the underlying barriers to diabetes care; and through effective care management increase their quality of life and decrease healthcare costs.


The Integrated Diabetes Care Program included three intervention sections: a) enhanced diabetes care in primary care practice offices; 2) incorporate diabetes self-management strategies; and 3) enhance behavioral health support and community engagement through care management. The intervention was delivered by the Registered Nurse Clinical Coordinators (RNCC), Community Health Workers (CHW), and Licensed Practical Nurses (LPN), and Licensed Social Workers (LSW), and AmeriCorps volunteer health coaches).


Key learnings from this project include:

  • Developing and implementing a patient-centered model of care proved successful in allowing providers to spend dedicated time with patients to understand their unique needs and address challenges through a coordinated team by meeting patients where they are.
  • Providers are changing the culture of their practice, restructuring their workflows, and changing how they understand and interact with patients, and transforming the way they provide care.
  • Building and maintaining a supportive, innovative culture is cultivated through practices of open dialogue, celebrating successes (no matter how small), continuous evaluation and correction, and exposure to ideas outside the organization.