Care management & redesign

We work directly with individuals with complex health and social needs to meet their own goals for health and well-being — and with partners locally and across the state to redesign systems to address the barriers our participants face.

Camden Coalition care team member leaving a participant's apartment after a home visit
I felt somebody really cares about me … I'm living, and I'm not here by myself. And I think that what's made me, you know, actually do it … I started taking my medication, I started, you know, getting out. "Diego," care management participant

Program timeline

COACH framework

COACH framework

Our participant engagement framework

RELATE framework
Camden Coalition care team members case conferencing

RELATE framework

Our reflective supervision framework

Housing First

Housing First

Housing and support for participants experiencing chronic homelessness.

Pledge to Connect

Pledge to Connect

Connecting ED patients to behavioral healthcare

Person-centered outcome measures
Care team members care planning with a participant during a home visit

Person-centered outcome measures

A learning collaborative from NCQA on implementing standardized measurement of patient-driven goals

Pregnancy care initiation
A pregnant patient sits on an exam table

Pregnancy care initiation

Connecting pregnant ED patients to timely pregnancy-related care

Camden Core Model
Care team leaving participant's house after a home visit

Camden Core Model

Person-centered care management for individuals with complex needs.

My Resource Pal

My Resource Pal

Social services search and referral platform

13 Programs in 2022

The Camden Coalition... [is an] exemplar of the kind of multidisciplinary, multisector efforts that will be necessary to address the complex needs of individuals and communities and make a lasting impact by eliminating health disparities, with the goal of achieving health equity. National Academies of Sciences, Engineering, and Medicine, "The future of nursing 2020-2030: Charting a path to achieve health equity"

U.S. healthcare and social services systems deliver medical, behavioral health, and social services in ways that do not always meet people’s needs, especially for those with complex health and social needs.

In response, the Camden Coalition designs person-centered programs and new models that address chronic illness and social barriers to good health. Supported by a robust data infrastructure, cross-sector convening, and shared learning, our community-based programs deliver better care to Camden and South Jersey.

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