News & Announcements

THT Awarded Research Grant to Study Health Care, Social Services Connections

Trenton NJ — Trenton Health Team is proud to announce a two-year research study funded by the Robert Wood Johnson Foundation seeking ways to better integrate social services, public health and healthcare to improve patient outcomes and well-being.

“Just seven projects were chosen from more than 150 applicants nationwide — so we are proud the country is going to be able to learn from the work we’re doing here in Trenton,” said THT Executive Director Gregory Paulson, principal investigator for the study. “This is an important problem to solve because community organizations are critical to improving patient well-being.”

Co-Principal Investigator Caroline Fichtenberg, PhD, a public health researcher, serves as Managing Director for SIREN and researcher in the Department of Family and Community Medicine at the University of California San Francisco, where she evaluates social need interventions in health care settings.

“Our study is squarely aimed at reducing health inequities,” Dr. Fichtenberg said. “This research project will help Trenton, as well as others around the country serving a high proportion of individuals facing social disadvantage, understand how to build networks that truly engage community-based organizations.”

In recent years, health care providers have recognized patient well-being depends on social and environmental factors not addressed by traditional clinical care — such as housing quality, food security, and poverty. To help address this, sophisticated data systems, such as NowPow, have been developed to enable health care providers to refer patients directly to food pantries, legal services, faith communities and other social services.

NowPow users can log-in to the community resource directory and referral platform to see what local agencies can best meet patients’ needs, immediately refer them for assistance, and then follow-up on results. Too often, however, community organizations providing these services are unable to participate in the referral process — leaving patients with fewer options for assistance.

The $346,500 grant will fund a study identifying barriers preventing community organizations from participating in these referral systems, and designing solutions to encourage and expand their participation so more residents can receive needed services. The study will address three questions:

  • What are the facilitators and barriers to community organizations actively participating in Trenton’s coordinated care network?
  • How do these facilitators and barriers differ across organizations?
  • What engagement strategies would encourage them to participate?


“We know this works for the health care side; now we want to explore what will make this work better for community organizations,” Paulson said.

A Project Steering Committee, including Trenton community agencies and national organizations, will guide the research. The study is funded by the Robert Wood Johnson Foundation, as part of the Aligning Systems for Health initiative, which seeks ways to better integrate health, care, public health, and social services to improve patient outcomes and well-being. See $2.4 million national grant announcement