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The Nicholson Foundation grant will help THT become a Medicaid Accountable Care Organization

$1.6M Grant Awarded to Trenton Health Team

(Trenton, NJ) — The Trenton Health Team, a community health improvement collaborative that serves the six zip codes of Trenton, has been awarded a $1.6 million grant by The Nicholson Foundation. The Newark-based foundation’s 18-month grant funds activities to help make Trenton the healthiest city in New Jersey.

“The goal of the grant is to prepare THT to become a Medicaid Accountable Care Organization by strengthening its organizational infrastructure and improving care coordination for the most frequent high-cost users of Trenton’s Emergency Departments and Inpatient Services,” said Joan Randell, deputy director of The Nicholson Foundation.

Dr. Ruth Perry, executive director of the Trenton Health Team, explained the focus on Medicaid ACOs. “In August 2011, the State of New Jersey passed legislation enabling healthcare providers to create Medicaid Accountable Care Organizations. This legislation permits urban healthcare pilot programs to share in cost savings they realize by implementing innovative healthcare models which increase care coordination, improve access to primary care, and utilize data to monitor the achievement of the ‘triple aim’ of better health in the overall population, better healthcare delivery and reduction in per capita costs of care.”

The grant supports two separate but related areas. The first area is expanding community-wide care coordination for Trenton patients who are high utilizers of emergency departments and inpatient services. A nurse-led care management team will focus on patients who, in addition to being high utilizers of emergency services, also have complex social needs. The other related area is expanding the organizational infrastructure of the Trenton Health Team. THT will build the capacity of the organization to become a successful Medicaid ACO by hiring additional staff to help achieve the organization’s strategic initiatives.

Each of the five strategic initiatives involves active and innovative programs. They are expanding access to primary care, improving clinical care coordination, utilizing data to understand and enhance population health, increasing community engagement and implementing the ACO business model.

“Our first step was to expand primary care access across all of the city’s clinics. Same day appointments are now available at Capital Health. St. Francis and Henry J. Austin Health Center,” said Christy Stephenson, president of the Trenton Health Team. “Nearly all players in Trenton’s psychosocial service network have partnered with the Trenton Health Team, yielding a deeper level of understanding of community health needs. And we are connecting directly with residents. We are still at the beginning of our efforts, but we are making progress. This new grant from The Nicholson Foundation will enable us to continue on our mission to improve health while at the same time containing costs that have spiraled out of control.”

The Trenton Health Team’s focus is on Trenton’s six zip codes, where 36.3 percent of the population of 114,168 is 200 percent below the federal poverty level, based on 2010 data. Dr. Perry said demographic and sociological statistics demonstrate that the THT is serving a poor and vulnerable population with significant unmet medical and psychosocial problems. The Trenton Health Team began addressing their health needs with funding from The Nicholson Foundation in 2011.

The Nicholson Foundation
The mission of The Nicholson Foundation is to work with families and communities to help their children become healthy, productive adults and realize their potential, by enhancing and connecting programs across the human-services delivery system.  The Foundation’s geographic focus is the State of New Jersey, with special emphasis on urban neighborhoods. For more information, visit

About the Trenton Health Team
Trenton Health Team (THT) is an alliance of the city’s major providers of healthcare services including Capital Health, St. Francis Medical Center, Henry J. Austin Health Center and the city’s Health Department. In collaboration with residents and the city’s active social services network, THT is developing an integrated healthcare delivery system to transform the city’s fragmented primary care system and restore health to the city. THT aims to make Trenton the healthiest city in the state. The THT receives generous support from The Nicholson Foundation, corporate partners and other foundations. For more information, visit