Camden Core Model

Person-centered care management for individuals with complex needs

Care team leaving participant's house after a home visit
The heart of our work is the Camden Core Model, which is our signature care management program.

Following the principles of trauma-informed care and harm reduction, our goal is to empower patients with the skills and support they need to improve their health and well-being.We use data to identify eligible individuals, most often through our Camden Coalition Community Health Information Exchange, using criteria that indicate considerable medical and social complexity. We then meet potential participants in-person, usually at the hospital bedside, to enroll them in the program.

Once participants are enrolled, an interprofessional team of nurses, social workers, and community health workers visits them in the community, helping them to reach their own goals for health and well-being. Our COACH framework guides our team in creating authentic healing relationships that build participants’ self-efficacy.

Depending on the participants’ goals and needs, care team members may help reconcile their medications, accompany them to doctor’s visits, and link them to social and legal services. Some of those social and legal needs can be met by more specialized programs within the Camden Coalition, like our Housing First program or Medical-Legal Partnership. For others, we connect them to services provided by our community partners.

Participants graduate from the Camden Core Model when they reach their goals through a combination of skill-building and connection to ongoing supports.

What makes the Camden Core Model different?

The Camden Core Model is not attached to one hospital or health system, since individuals with complex needs often engage multiple systems. We recognize that much of what drives health takes place outside the four walls of medicine, and that no one program or service can address all of an individual’s complex health and social needs.

Over the years, our care management approach has evolved to spend as much time linking patients to social supports as to healthcare. We respond to barriers and gaps that participants face by addressing them directly, on a systems level.

As an organization, our goal is to create a strong, interconnected, and responsive ecosystem of care in Camden so that care management programs like the Camden Core Model are no longer necessary.


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