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.
Horizon Neighbors in Health
THT launched the Horizon Neighbors in Health program in April 2020 serving Horizon BCBSNJ clients. The program aims to address Social Determinants of Health (SDoH), the complex, integrated and overlapping social structures and economic systems responsible for most health inequities. Traditional care delivery lacks the time, skills and community linkages required to address these factors. (See story in Trenton Daily)
Usually, community health workers would visit clients at home but due to COVID-19 safety measures, THT staff are contacting clients remotely to conduct SDOH assessments, identify issues clients face, and then work with clients to set specific goals to address them. For example, THT staff have responded to clients’ needs by providing face masks and sanitizer, and delivering food and medicine to their homes. See THT press release
The program is available in 11 counties statewide — including Mercer County — serving clients in 70 zip codes. Client participation is voluntary and Horizon BCBSNJ encourages referrals to local resources, coordination with their Personal Health Assistants (PHAs) and use of available Horizon BCBSNJ mitigation funds to help secure certain items or services not available in the community. By helping improve client health outcomes, Horizon BCBSNJ is seeking to improve care quality while reducing healthcare costs. See Horizon TV story about THT program.
Comparing Trenton or Mercer County data with New Jersey rates: