THT: A Holistic Approach to Social Services

The 2019 Trenton Community Health Needs and Assets Assessment revealed through a resident survey of over 1400 individuals and 10 community forums that there is an abundance of free and lowcost services in Trenton. While Trenton is rich in social services (one community member said “no one in Trenton should go hungry,” alluding to the abundance of food pantries and places to get free meals in the city), these services often lack coordination with one another, with this reflected in the patient or client experience.

Meetings with the Community Advisory Board revealed coordination between health care and social service facilities was also weak, and that many community resources were being underutilized. Clinical and social service staff representing different organizations came to understand that the patient at the local federally qualified health center was also visiting a nearby food pantry regularly and was also engaged with a community organization to remediate lead and mold in the home. The acknowledgement that one individual was receiving services across health care and social service providers that often didn’t coordinate or communicate with one another prompted a call to action, one that demanded a means to communicate, share information and hold referral receiving agencies accountable.

This April 2019 report outlines THT’s efforts to address that need.

  • Publication date

    April 2019

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