For the Media

Trenton Health Team Fact Sheet

The Trenton Health Team (THT) is a community health improvement collaborative serving the six zip codes of Trenton, NJ.  The collaborative is an innovative partnership among Capital Health, St. Francis Medical Center, Henry J. Austin Health Center, and the Department of Health and Human Services of the City of Trenton.  The vision of the Trenton Health Team is to make Trenton the healthiest city in the state.  Our mission is to transform healthcare for the city by forming a committed partnership with the community to expand access to high quality, coordinated, cost-effective healthcare.

THT is unique in its public-private, community-wide collaborative structure, with all the city’s key healthcare providers actively engaged.  THT first came together in 2006 as the result of a study commissioned by Mayor Douglas Palmer to assess the impact of the proposed closure of Mercer hospital.  In response to this call for action and as a key recommendation in the consultant’s report, fierce competitors were brought together to resolve challenges.  As the city’s healthcare providers began to find common ground, a partnership grew among former competitors and THT was formally constituted as a 501(c)(3) non-profit in February, 2010.

THT’s strategic initiatives include:  Expanding access to primary care; improving care coordination and care management; operating a regional 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 serving as a certified Medicaid Accountable Care Organization (ACO) – all of which support the Triple Aim of improved patient experience, better patient outcomes, and lower healthcare cost.

THT can point to significant accomplishments.  For example, access to care has been improved through adoption of a medical home model city-wide and an open access or “same day” scheduling system.  The Community-wide Clinical Care Coordination Team (C4T), composed of physicians, case managers, nurses, and social workers from the THT partners as well as representatives of community behavioral health and social service agencies, was able to reduce ER use by more than 45% across the city by focusing on data analysis to identify the highest utilizers.  Establishment of the Trenton HIE, launched in January, 2014, enhances these efforts by allowing real-time, shared access to patient data across partner organizations, supporting improved coordination and efficiency in the delivery of healthcare services.

Trenton residents served as key participants in a comprehensive, unified Community Health Needs Assessment (CHNA), which confirmed and quantified critical care issues for Trenton.  The priorities that emerged through quantitative and qualitative analysis were:  health literacy and disparities; safety and crime; obesity and healthy lifestyles; substance abuse and behavioral health; and chronic disease: diabetes, hypertension, and cancer.  THT’s projects and initiatives are targeting these public health priorities in order to improve health outcomes for the city’s residents.  In addition, patients who represent the highest utilizers of emergency and inpatient services can receive support from our nurse-led Care Management Team, comprised of healthcare professionals who work with individuals to develop and implement a customized, coordinated care plan, often with remarkable health improvements for our clients.

Through certification as a Medicaid ACO, THT is building on its collaborative efforts to ensure that all residents within the six zip codes of Trenton receive coordinated healthcare that is evidence-based and data-driven. Increased awareness of healthy lifestyle choices coupled with increased access to and coordination of health care services will move the city towards a culture of health.  Continued outreach is being done to promote health literacy and knowledge regarding preventive health strategies, to increase enrollment in health insurance for which residents are eligible, to enhance access to primary and specialty care, and to provide care coordination for the highest utilizers – all of which will help to reduce avoidable emergency visits and inpatient hospital stays.  Patients also benefit from Clinical Decision Support Systems that have been developed across clinical partners and link to the Trenton HIE.


Key initiatives:

Trenton Health Information Exchange:  The HIE has grown to include more than 250,000 individual patient records and over 600 system users.  Shared access to real-time patient data allows providers to have a more complete picture of patients’ medical history, thereby avoiding potentially duplicative testing and improving diagnostic accuracy.

Care Coordination:  Through the Community-wide Clinical Care Coordination Team (C4T) and our nurse-led Care Management Team, which conducts regular and ongoing outreach across the community, we are targeting the highest-need patients, connecting them to a range of resources including social services plus primary and specialty care, and following up to ensure that services are received and prescribed regimens are followed.

Clinical Decision Support System:  Customized reports and protocols that are built into the HIE allow providers to offer consistent, evidence-based care across their patient panels for key diagnoses such as diabetes and hypertension.

Community Engagement/Community Health Improvement:  In partnership with our Community Advisory Board, which includes representatives from more than 60 behavioral, social service, educational, and faith-based organizations, we are implementing a plan that focuses on the priorities identified through the CHNA.  Key grants (below) are supporting projects to address health literacy, healthy lifestyle choices, and access to basic health screenings and referrals.


Major funders:

The Nicholson Foundation:  THT has received substantial funding to support preparation for and implementation of the Medicaid ACO Demonstration Project (2011-2015, 2016).

New Jersey Department of Health:  Grants for Clinical Decision Support System development and deployment; ‘Faith in Prevention’ to implement Faithful Families Thriving Communities curriculum in partnership with faith-based organizations; implementing the Stanford University Chronic Disease/Diabetes Self-Management Programs with community partners who serve vulnerable populations (2014-2016).

The Robert Wood Johnson Foundation:  Support for Community Health Needs Assessment (2011-2013); community-wide training program in Trauma-informed Care (2015-2016).

Novo Nordisk, Inc.:  ‘Stepping Up to Transform Our Health’ was designed to encourage good nutrition and healthy lifestyle choices (2014-2015); Community Health Collaborative™ is bringing Trenton Public Schools and community-based organizations together to provide in-school and afterschool programming aimed at developing healthy lifestyles, including good nutrition and active living, for a targeted group of 2nd and 3rd grade students who will be followed for a period of 3-5 years (2016).

Janssen Pharmaceuticals:  ‘Inroads for Health: Taking it to the Streets’ uses the City of Trenton’s mobile health van to bring basic health screenings and referrals to residents where they are, including health fairs and the new Greenwood Ave. Farmers Market every Monday from mid-June through October (2015, 2016).

Trinity Health:  ‘Transforming Communities Initiative’ is a comprehensive, 5-year project focused on improving population health through evidence-based strategies addressing social determinants at the policy, systems, and environmental level (2016).