Trenton Health Team and Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) have partnered to provide state health benefit plan members with services addressing social and environmental issues affecting their health.

“The state’s largest insurer recognizes patient well-being depends on social and environmental factors such as housing quality, food security, and poverty–and they appreciate the expertise of our Care Management Team in building close relationships with clients to address those issues,” said THT Executive Director Gregory Paulson.

Since THT launched the Horizon Neighbors in Health program in April, more than 55 clients have enrolled in the program which aims to have approximately 300 participants over the course of the first year. To serve Horizon BCBSNJ clients, THT expanded its community health staff.

Usually, community health workers would visit clients at home but due to COVID-19 safety measures, THT staff are contacting clients remotely to conduct a Social Determinants of Health (SDoH) assessment, 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.

Horizon Neighbors in Health aims to address 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.

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.

“We are truly empowering our members to live their best lives through increased availability of options and information,” said Valerie Harr, Horizon BCBSNJ’s Director of Community Health, Enterprise. “We see this as a model for the rest of the nation.”

THT is eager to build on its care management work and help new clients move toward better health by addressing the SDoH affecting their lives. The critical element, Paulson said, is the community health worker’s ability to connect with a client, build trust and support lifestyle changes.

“It’s hard for anyone to say ‘I need help’,” Paulson said. “Our staff know the community–many live here in Trenton–and they are dedicated to connecting clients with needed services, whether medical or social.”