Success Story Submission for Association for State and Territorial Health Officials

Name of the Main Organization: Trenton Health Team

Other Participating Organizations: Capital Health, St. Francis Medical Center, Henry J. Austin Health Center, City of Trenton Department of Health and Human Services

Name and Title of Submitter: James Brownlee, MPH, President, Trenton Health Team

Contact Information of Submitter: [email protected], 609-815-2556

Brief Description of the Innovation: The Trenton Health Team (THT) is an innovative partnership among Capital Health, St. Francis Medical Center, Henry J. Austin Federally Qualified Health Center, and the Department of Health and Human Services of the City of Trenton. The mission of THT is to transform healthcare for the city of Trenton by forming a committed partnership with the community to expand access to high quality, coordinated healthcare.

THT is unique in its public-private, community-wide collaborative structure and in its shared commitment to health improvement within the six zip codes of Trenton, NJ. THT is expanding access to primary care, improving care coordination and management, increasing efficiency through the use of data and technology, and engaging the community to overcome obstacles to quality care – all of which are leading to improved health outcomes and lower healthcare costs.

The THT structure is innovative in its collaboration among organizations that have traditionally been competitors or have operated in silos. Not only do the competitors work together, but there is active, ongoing participation through weekly meetings of the Executive Committee, where all corporate partners are represented, and monthly meetings of the Community-wide Clinical Care Coordination Team (C4T). The C4T is integral to the THT innovation, bringing together medical and behavioral health providers from across the city to review particular cases, issues, and strategies for achieving the triple aim of improved patient experience, patient outcomes, and lower cost. The C4T has created task forces to tackle specific conditions and challenges, such as sickle cell disease, behavioral health, and medical high-risk.

Another innovative feature in the partnership is the fact that THT consciously seeks to bridge the gap between public health and traditional healthcare. This is achieved by including representation from all the hospitals and the city’s only FQHC along with the City of Trenton’s Director of Health and Human Services in the Executive Committee, and representation from the State Department of Health plus the city’s major social service agencies on our Board of Directors.

THT had its origins in 2006, when the Mayor of Trenton commissioned the Katz Consulting Group to develop a plan to improve the status of health and healthcare services for the city's residents. The Katz

218 North Broad Street |Trenton, New Jersey 08608|609-989-3262|609-989-4267(f) www.trentonhealthteam.org Group found that Trenton residents were 54% more likely to utilize the emergency department than the national norm, only 52% obtained primary care visits, and Trenton residents used hospital outpatient departments nearly 21% less than the national norm. In addition, Trenton residents were admitted to hospitals nearly 40% more often and were often readmitted for lack of follow-up care. (Katz Consulting Group, Inc.; Making Trenton’s Healthcare Plans a Reality, 2006) Recommendations in the Katz report were the genesis for THT, bringing together key health providers to collaborate and implement a new vision of healthcare for the city.

THT is taking a multipronged approach to improving health services for the city. THT’s five strategies include: expanding access to primary care; improving care coordination and care management; establishing a Health Information Exchange to provide real-time access to shared patient data; engaging the community to increase knowledge and overcome obstacles to care; and building the infrastructure to become a Medicaid ACO. Through our integrated medical home model, we are offering a patient-centered approach that eliminates duplication of services and excess costs. We have been able to match most patients with a designated caregiver who gets to know them and helps coordinate their care. All of THT’s partners also adopted business principles to reduce clinic wait times, with significant success. In addition, a project funded by The Nicholson Foundation has allowed THT to deploy a nurse-led care management team to focus on supporting and educating Trenton’s most frequent emergency users.

In another innovation, THT utilized the Internal Revenue Service's (IRS) Community Health Needs Assessment (CHNA) and Community Health Improvement Plan (CHIP) obligation as an opportunity to complete a community health needs assessment for the city's geography in an original way. First, a unified community health assessment was performed in place of separate assessments as was done in the past. Second, the approach was shifted from one that viewed this as a “requirement” to one that engaged the community to illuminate the successes as well as the barriers and challenges Trenton residents face in maintaining their health. THT used forums and one-on-one interviews to hear the voice of the community, identifying their most significant health challenges and barriers to care. This process (which is described in detail in Population Health Management, Volume: 16 Issue S1: September 26, 2013) has resulted in a unified CHNA and CHIP for the city of Trenton, allowing collaborative allocation of resources to manage and improve population health in the city.

Finally, with New Jersey’s planned expansion of ACOs to include impoverished populations enrolled in Medicaid, THT is poised to focus more fully on Trenton's vulnerable population. As a Medicaid ACO, we hope other cities can follow our innovative example of public-private partnerships to give vulnerable populations a new chance to lead healthy lives.

Brief Description of Results: Since being formally constituted in 2010, THT can point to significant accomplishments. For example, access to care has been improved through adoption of a medical home model city-wide and an open access or “same day” scheduling system, resulting in reduced patient wait times (37 days down to two days at Henry J. Austin) and improved patient provider continuity (0% to over 95% at St. Francis Medical Center). The Community-wide Clinical Care Coordination Team (C4T), composed of physicians, case managers, nurses, and social workers from the THT partners as well as representatives of community behavioral health and social service agencies, meets monthly and focuses on data analysis to identify highest utilizers of emergency rooms, resulting in reductions of ER use by more than 45% across the city.

218 North Broad Street |Trenton, New Jersey 08608|609-989-3262|609-989-4267(f) www.trentonhealthteam.org The THT partnership also enabled the City health department to come into compliance and, together with THT, receive Health Resources and Services Administration (HRSA) Free Clinic status to reopen the City’s Pediatric and Adolescent Treatment Center, which is staffed with volunteer doctors, physician’s assistants, nurse practitioners, and nurses to serve the uninsured patients of our community. There are currently plans to expand this clinic to provide primary care for adults and to provide specialty care for the uninsured population of Trenton.

Description of Health Care Setting: The setting for THT’s work is the community, defined specifically as the six zip codes of Trenton, NJ, including both clinical and non-clinical settings within that geography. THT’s comprehensive approach is anchored in an innovative public-private partnership that includes the City of Trenton, all of Trenton’s hospitals, Trenton’s only Federally Qualified Health Center (FQHC), and additional partnerships that have been forged with more than 30 social service agencies, behavioral health providers, educational institutions, and faith-based organizations that serve the city of Trenton.

Description of the Population on Which the Innovation is Focused: THT was established to serve residents of Trenton, which is one of the poorest cities in the state of New Jersey, with a 2011 per capita income of $14,621. Among Trenton residents, 52% are African American and 30% Hispanic/Latino; 31% have hypertension, 16% diabetes, and 39% are obese. A recently completed Community Health Needs Assessment, funded by the Robert Wood Johnson Foundation, has confirmed and quantified a number of critical care issues, including sickle cell disease, substance abuse and behavioral health, diabetes, hypertension, and cardiovascular disease. Significant barriers to care were also identified. These include health literacy, safety and crime, and transportation challenges, all of which relate to the overarching priority of poverty, which is pervasive. Many of the neediest (and costliest) patients in the city are homeless, have chronic health conditions, and have few supports for ensuring that treatment regimens are properly maintained. Through the Community-wide Clinical Care Coordination Team and our nurse-led Care Management Team, which conducts regular and ongoing outreach across the community, we are targeting the highest-need patients, connecting them to a range of resources including primary and specialty care, and following up to ensure that services are received and prescribed regimens are followed.

Funding Sources for the Innovation: From the outset, member organizations of THT have provided substantial cash and in-kind support to ensure that THT not only survives, but thrives. Leaders from each of the corporate entities (Capital Health, St. Francis Medical Center, Henry J. Austin Health Center, and the City Department of Health and Human Services) serve on the THT Executive Committee and Board of Directors, contributing hours and services on a regular basis and exercising the authority to implement operational changes within their respective institutions. THT has also received grants from a number of prestigious organizations including The Nicholson Foundation, the Centers for Disease Control, the State of New Jersey, Mercer County, the Horizon Foundation for New Jersey, and New Jersey Health Initiatives (NJHI), a statewide grant-making program of the Robert Wood Johnson Foundation. It is notable that THT bylaws stipulate that any grant funding over $100,000 per year will be sought through THT, and member entities have agreed not to compete with each other for funding, but instead to seek funding together to build THT – another innovative dimension that helps to solidify and sustain the collaborative structure.

218 North Broad Street |Trenton, New Jersey 08608|609-989-3262|609-989-4267(f) www.trentonhealthteam.org