Trenton Health Team Transforming Healthcare for the Community

Trenton Health Team Transforming Healthcare for the Community, with the Community Gregory Paulson, Executive Director New Jersey Population Health Summit - September 14, 2016

THT History Background § Declining public health indicators in Trenton § Lack of primary care access & lack of collaboration between providers § Closure of an Acute-care Hospital (Capital Health – Mercer Campus) Katz Report 2006: § Create an integrated health care structure § Provide specialty care through improved funding and access § Develop consumer engagement strategies and plan § Establish a health database and information system linking Trenton providers § Expand primary care access § Improve public health indicators Four Founding Partners: 2

Our Community Demographics: • 84, 034 population • 52% African-American • 34% Hispanic (underrepresented, from Census data) • 26% living in poverty (200% FPL) with average household income of $36, 662 (contrasted with NJ poverty rate of 11% and average income of $71, 629) • Violence rates 4 -5 times NJ average • Disease prevalence: • Hypertension 31% • Diabetes 16% • Clinically Obese 39% • 2013 Community Health Needs Assessment (http: //www. trentonhealthteam. org/wp-content/uploads/THT-CHNA-2013 -July. pdf)

Five Strategic Initiatives Expand Access to Primary Care Advance Access Scheduling FQHC Collaboration/Expansion New Access Points C 4 T Community-Based CMT Community-wide Care Coordination and Management Engage the Community Utilize Data to Improve Population Health CAB Inroads for Health CHNA/CHIP Novo Nordisk - CHC Faith in Prevention Trinity Health - TCI Trauma-Informed Care Expand Infrastructure for an Urban Medicaid ACO NJ Medicaid ACO Demo Project Backbone Infrastructure Citywide High Utilizer Analysis Trenton HIE Clinical Decision Support

Early Work: Care Coordination Community-wide Clinical Care Coordination Team (C 4 T) ED High Utilizer focus § Lady B 2010 -2011 § 465 ED visits § Clifton 2010 – 2011 § 64 unplanned encounters § 6 Inpatient stays Top 50 ED July- Dec 2010 Jan-June 2011 July-Dec 2011 Jan-June 2012 % Change # ED Visits 2, 398 1, 633 1, 501 1, 321 45% Reduction # IP Stays 181 98 78 88 51% Reduction Charges $10. 8 million $6. 6 million 39% Reduction 5

Early Work: Unified CHNA Community Advisory Board Priorities Inform Community Health Improvement Plan and Healthcare Information Dashboard Community Health Needs Assessment Reveals Priorities Merge Data & Link to Healthcare Utilization Data (Quantitative) Community Engagement: Forums and Personal Interviews (Qualitative)

Community Advisory Board 29 agencies started CHNA process 2012 2016 60+ agencies, 145 representatives CHNA/CHIP, Trinity Health, Plan 4 Health, Healthy. Trenton

Trenton HIE and Community-wide Data

Community Partnerships

Celebrating Successes

Keeping in touch… Gregory Paulson gpaulson@trentonhealthteam. org 609 -256 -4555 x 188 www. trentonhealthteam. org