A Camden County Correctional Facility pilot
Care management & redesign Data analysis & integration Data sharing Quality improvement SDOH & health equity
This resource is a part of our “snapshot” series. A snapshot is a point-in-time window into our process for developing, testing, and implementing programs and partnerships. Snapshots let us share our hypotheses, workflows, and early observations and findings quickly with other innovators who are interested in what’s happening on the ground right now.
From 2023 to 2024, the Camden Coalition partnered with the Camden County Correctional Facility and the Center for Family Services (CFS), a regional social services provider, to create an automated health and social care referral workflow for previously incarcerated individuals reentering their communities. Prior to this program pilot, individuals returning to the community had difficulty connecting to community-based organizations. By enabling Camden County Correctional Facility’s reentry specialists to send referrals and reentry plans directly to CFS’s Peer Reentry Support Program through our centralized My Resource Pal platform (powered by Findhelp), the program reduced information gaps and sped up communication, leading to reduced referral delays. The pilot also laid the groundwork for incorporating use of the Camden Coalition Health Information Exchange into the reentry process to better align medical and social care referrals, offering a scalable model for other county jails across South Jersey.
Center for Family Services (CFS) — A local multiservice non-profit organization that operates the Peer Reentry Support Program and supports returning citizens, connecting them to a broad array of services.
Camden County Correctional Facility — Camden County, New Jersey’s correctional facility responsible for the custody and release of incarcerated individuals. Its reentry committee, established in 2017, oversees reentry policies and created the reentry specialist role-staff who develop transition plans, share medical information, and connect individuals to community-based services.
Camden Coalition’s My Resource Pal, powered by findhelp — The Camden Coalition’s resource navigation platform that helps individuals find and connect to community services such as healthcare, housing, and social supports. It is used by the jail, social service providers, and individuals seeking assistance for themselves or others.
Returning citizens—individuals who are scheduled to return to their communities following incarceration—often face significant barriers to reentry including limited access to community-based programs and services. This lack of access makes it difficult to secure healthcare, mental health and substance use treatment, housing, employment, and public benefits, all of which are critical for a successful transition. Quickly connecting returning citizens to these essential services via coordinated support promotes stability, reduces recidivism, and supports long-term reintegration.
While correctional facilities like the Camden County Correctional Facility employ reentry specialists to develop transition plans, share medical information, and provide referrals to community-based organizations (CBOs), these efforts can be undermined by systemic challenges—such as fragmented service systems—that continue to hinder successful reintegration.
To ensure individuals leaving Camden County Correctional Facility receive coordinated support from reentry specialists and community-based providers for a smooth and successful transition back into the community using a new, automated workflow between the Camden County Correctional Facility and the Center for Family Services.
The Camden County Correctional Facility Reentry Department coordinates reentry social supports through the Center for Family Services (CFS), which provides returning citizens assistance with housing, substance use disorder (SUD) treatment, halfway house coordination, and behavioral health services via their Peer Reentry Support Program. Prior to the Camden Coalition’s involvement with the county jail’s reentry process, the reentry department could only provide CFS a list of upcoming or very recently released individuals, along with a brief list of their support needs. The likelihood of the individuals connecting with CFS once they were released, however, was low regardless of how much information and workup time their reentry specialist provided, as the process relied on manual communication methods—such as phone calls and paper lists—leaving gaps in timing, follow-up, and real-time coordination.
The Camden Coalition and Camden County Correctional Facility have a long-standing partnership focused on improving care coordination for justice system involved individuals. Previously, they developed healthcare coordination solutions through the Camden Coalition’s Health Information Exchange (HIE)—a secure data-sharing platform that supports regional care management, clinical redesign initiatives, and real-time collaboration among approximately 50 organizations across South Jersey and beyond. Building on this strong foundation, Camden County Correctional Facility identified reentry as a critical area of need and turned to the Camden Coalition, which they knew also operated My Resource Pal, to co-design an innovative solution leveraging these existing platforms to better support individuals returning to their communities.
The Camden Coalition developed a customized workflow within My Resource Pal to create a secure, automated referral pathway between the jail’s reentry specialists and CFS’s Peer Reentry Support Program.
When an individual was scheduled for release from jail, the Camden County Correctional Facility reentry specialist sent referrals directly to CFS via My Resource Pal, ensuring that both organizations—and the returning citizen—had access to the same reentry plan on a shared platform. Returning citizens received direct notifications about their referrals, helping them understand and act on their next steps. This streamlined approach eliminated many of the communication gaps and follow-up challenges that had previously led to inconsistent outcomes, ultimately improving coordination and support for individuals as they transitioned back into the community.
The reentry program fielded 455 referrals during the pilot period of October 2023 – April 2024. In all, 384 incarcerated persons were placed into the program.
An anonymous survey of the jail’s reentry department administered by the Camden Coalition in May 2024 showed all participating reentry specialists and case managers either agreed or strongly agreed that they would recommend My Resource Pal for sending and receiving referrals. All but one agreed or strongly agreed that the program helped to meet participants needs. Overall, the Camden County Correctional Facility observed a decreased amount of time for post-incarceration referrals, as well as reduced risk of missed referrals among individuals reentering their communities.
This pilot program allowed Camden County Correctional Facility to better coordinate reentry with CFS by establishing a secure, automated referral workflow pilot that improved communication, increased follow-up consistency, and streamlined how returning citizens connected to essential services. It provided a replicable model for other correctional facilities to adopt in partnership with their own regional CBO networks and demonstrated the value of integrating the Camden Coalition’s HIE and My Resource Pal—two separate but interconnected platforms that bridge healthcare and social service referrals.
This integration not only strengthened Camden County Correctional Facility’s reentry process but also served as a strong proof of concept for how technology can streamline care coordination across sectors. While the use of this specific workflow was paused when the pilot funding ended, the Camden County Correctional Facility is exploring restarting this workflow with expanded referral functionality.
Building on these results, the Camden Coalition plans to replicate the model with additional South Jersey correctional facilities interested in improving continuity of care for individuals reentering their communities. Based on the success of the pilot, the Camden Coalition will continue aligning the strengths of both platforms—leveraging the HIE for healthcare-focused referrals and My Resource Pal for social care referrals—to further enhance reentry outcomes and support for returning citizens.
Arley Styer
Associate Director, Health & Community Information Exchange & Partnerships
[email protected]
Since 2010, the Camden Coalition HIE has provided South Jersey hospitals, health systems, and care providers real-time access to patients' medical information via a secure, web-based portal.
Building the complex care field Data analysis & integration Strengthening ecosystems of care Convening Data sharing Measurement & evaluation Quality improvement SDOH & health equity