What We Do

Trenton Health Team is taking a multi-pronged approach to improving health services for the city. THT’s five strategies include: expanding access to primary care; improving care coordination and care management; operating a Health Information Exchange (HIE) to provide real-time access to shared patient data; engaging the community to increase knowledge and overcome obstacles to care; and functioning as one of three certified Medicaid Accountable Care Organizations (ACO) in the State of New Jersey’s Demonstration Project.  All of our initiatives are designed to improve health outcomes and reduce healthcare costs.

Access to Care

Through all of our efforts and initiatives – care coordination, community partnerships, data management – we are connecting people to the care they need. We are making it easier to obtain appointments through Advanced Access Scheduling as we also reach into the community to provide health screenings, assessments, and referrals to services for individuals who are underserved or experience barriers to care such as language and culture.

Care Coordination and Management

The Community-wide Clinical Care Coordination Team (C4T) is integral to the THT innovation, bringing together medical and behavioral health providers from across the city to review particular cases, issues, and strategies for achieving the triple aim of improved patient experience, patient outcomes, and lower cost. The C4T has created task forces to tackle specific conditions and challenges, such as sickle cell disease, behavioral health, and medical high-risk.

Our Care Management Team (CMT) is also vital to care coordination. Working with the highest utilizers of Trenton’s emergency room and inpatient services, THT’s Care Management Team offers complete care known as wrap-around services, which include social and psychological services as well as primary healthcare. The four-member CMT includes a nurse case manager, a social worker, and two community outreach workers who develop a personal relationship with each CMT client, building trust and knowledge that moves them toward self-management and improved health outcomes.

In addition, THT provides coordination of care for active and suspected tuberculosis patients throughout Mercer County. As part of the statewide regionalized program coordinated by the NJ Department of Health, THT’s TB Nurse Case Manager has specialized training, knowledge, and experience caring for these patients and preventing the spread of disease.  The TB program receives direct support from Mercer County and each municipality’s local Board of Health.

Community Partnerships

Community partnerships are central to the structure of THT and essential to how we do our work. Beginning with the unified Community Health Needs Assessment (CHNA), conducted in collaboration with St. Francis Medical Center, THT recognized the importance of working across sectors and of hearing directly from our residents regarding their healthcare experiences and related concerns. Working within a range of community partnerships, we serve as convener, catalyst, and collaborator to improve both the system of healthcare services and outcomes for those who are served.

The Community Advisory Board (CAB) was established to guide the CHNA process and to provide ongoing input and access to data and issues pertaining to health and, most importantly, to the social determinants of health. Through a series of 30 forums and 300 one-on-one interviews conducting in a range of settings, the voice of the community was a vital component of the 2013 CHNA.

Since its founding in 2011 with 29 member organizations, the CAB has grown to more than double that number, with representatives who meet regularly in work groups to address the priority areas that emerged from the CHNA process. It was these work groups who developed a Community Health Improvement Plan (CHIP), which was adopted in 2014 by the CAB and has led to a number of projects that are supporting further education and engagement of community residents in the identified priority areas. These projects include: Go Mobile for Health, development of a Clinical Decision Support System for Diabetes and Hypertension, Faith in Prevention, Foundations for a Trauma-informed Culture of Health, Inroads for Health, participation in the Robert Wood Johnson Foundation Building a Culture of Health: Communities Moving to Action, the Novo Nordisk-conceived Community Health Collaborative, the Trinity Health Transforming Communities Initiative, and the RWJF-funded Advancing Inroads for Health, the BUILD Health Challenge, and the Merck Foundation-supported Bridging the Gap: Reducing the Disparities in Diabetes Care.

Health Data – The Trenton Health Information Exchange

A signature accomplishment has been THT’s development of the Trenton Health Information Exchange (HIE), launched in 2014 as a shared data platform for our founding partners, Capital Health, St. Francis Medical Center, Henry J. Austin Health Center, and the City of Trenton Department of Health. It provides health practitioners access to integrated and holistic patient records in real-time to support treatment decisions and strategies. The HIE also plays a vital role in advancing efforts to improve our community’s health, allowing the creation of integrated reports and protocols that are designed to identify issues, trends, and particular health needs or disease conditions where interventions are warranted. The HIE has grown quickly as providers and data partners learn the value of this real-time informational resource. The reporting functions of the HIE are being continuously enhanced to include analytics at both the macro (population) and micro (individual, disease category, age group, or other subset) levels.

Medicaid Accountable Care Organization

Trenton Health Team was certified by the New Jersey Department of Human Services as one of the first Medicaid Accountable Care Organizations (ACO) in the State, serving the greater Trenton community. The ACO pilot is for a three-year period, effective July 1, 2015. An ACO is a healthcare model that has the three-part goal of improving health outcomes, lowering healthcare cost, and improving the patient’s experience of receiving care. While the ACO model has been tested and found to be effective in achieving improved outcomes and reduced costs within Medicare, this adoption for Medicaid represents an important innovation in the design. Through this model, the THT-ACO is responsible for the health of all Medicaid beneficiaries residing in the six zip codes of Trenton.