Projects

Care Management

Trenton Health Team’s Care Management Team (CMT) provides social, psychological and health care support to Trenton residents with complex health and social conditions, based on referrals from community partners. 

Care Management is rooted in an effort by city healthcare providers to address the high utilization of emergency rooms across the city prompted by the lack of primary care services. The goal of Care Management is to ensure patients receive quality care and can manage their conditions effectively to achieve the best possible outcomes–often preventing time-consuming and expensive visits to the emergency room. 

Most Care Management patients are coping with one or more chronic conditions, and require care that an emergency room is not designed to provide, such as consistent monitoring and education, and an ongoing relationship to manage the illness and reduce the likelihood of complications. 

Our CMT includes a nurse care manager, a social worker, four community health workers, and a community health coordinator. The team embraces whole-person care, screening for Social Determinants of Health (SDOH) and addressing challenges beyond the exam room that impact health and well-being. 

To help patients access the full range of services they need, a member of the CMT may accompany a patient to appointments, take them to the pharmacy for medications and help connect them with social services to address needs related to food, clothing, shelter and finances.  

Our CMT strives to educate patients about their conditions, and connect them with ongoing care so they no longer rely on emergency room visits to manage their health. Visiting multiple emergency rooms and receiving treatment from different clinicians means treatment can be fragmented, repetitive or contradictory. Emergency room care may temporarily solve a problem but cannot manage conditions over the long term.


Indicators


Comparing Trenton or Mercer County data with New Jersey rates:

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