After a successful pilot project in Newark — built largely around community health workers who visited people at home to help address medical and social concerns — and nearly a year of planning, New Jersey’s largest health insurer was ready to expand the initiative to reach 24,000 vulnerable patients in 11 counties.
Then came the coronavirus, and with it, new precautions and restrictions designed to contain the spread of COVID-19. Those pandemic protocols made it impossible for the company, Horizon Blue Cross Blue Shield, to roll out the program as planned.
But the viral outbreak also underscored the importance of the program itself, Horizon officials note, so they decided to press forward — with modifications.
“How could we not?” said Valerie Harr, Horizon’s director of policy integration, transformation and community health. “What we see is that the coronavirus has exposed all these inequities and health disparities that this program is designed to address.”
As a result, BCBS worked with its eight partners — including the state’s three largest hospital systems, key community groups, academics and a technology company — to regroup and to retool the program, Horizon Neighbors in Health, utilizing telemedicine and other “remote care” options.
The revised program — grounded in a unique predictive model designed to identify individuals in specific zip codes who have rising health risks — was launched in early April, with a $25 million commitment from Horizon over three years.
Addressing social determinants
The initiative focuses additional attention on addressing the social determinants of health — issues related to poverty, education, the environment, race, childhood trauma, violence and other factors — that play an outsized role in patient wellness. While estimates vary, Horizon said these factors account for roughly 65% of an individual’s health, with medical care impacting 35%. The coronavirus pandemic has exacerbated most of these concerns and with thousands of state residents now out of work, more people are struggling economically.
COVID-19 — which has been diagnosed in more than 149,000 New Jerseyans, including nearly 10,600 who have died — has also taken an outsized toll on African Americans and other communities of color, who are more likely to have limited access to care or have underlying conditions that make them more vulnerable. Black residents make up 14% of the state’s population, but are nearly 18% of the diagnoses and close to 19% of the fatalities, according to the latest state data.
“We’re experiencing every day these longstanding inequalities,” said Gregory Paulson, president and CEO of the Trenton Health Team, a collaboration of health care providers, public agencies and local nonprofits that partnered with Horizon to expand the Neighbors in Health program throughout the state. “But COVID has shined a bright light on these in a way that other people are now seeing.”
Horizon — which insures 3.5 million New Jerseyans, more than half of those with coverage — initiated the Newark Neighbors pilot three years ago, with outreach to 1,000 people insured by the company within four zip codes in the South Ward. These were identified by the company as having chronic health conditions or other issues that suggested they were at a “rising risk” for developing more complex medical and social needs.
The company partnered with RWJBarnabas Health and recruited, hired and trained a crew of city residents to work as community health workers, based at the network’s Newark Beth Israel Medical Center. These employees served as critical emissaries for the program, officials said, meeting and gaining the trust of patients at hospital bedsides, through referrals from family doctors, or via cold calls followed by home visits.
Community connection is key factor
Deploying health workers from the same community as patients was key, Horizon said, providing for a personal connection that allowed conversations about hunger, job skills, poverty itself, domestic violence and other highly personal topics. Jennifer Velez, executive VP of community health for RWJBarnabas, said effective community health workers were “probably the biggest ingredient for success” of the program.
“Often, none of this would be picked up in a clinical setting,” she explained.
Velez and others hope the expanded project will demonstrate to Horizon and other insurance companies the benefit of covering community health worker visits for all appropriate patients. “It’s really somebody’s story. It’s so much more complicated than what can be done in a 10-minute visit,” she added.
Health workers helped connect patients with benefits they may not otherwise have known about, like mail-order prescriptions through Horizon, telemedicine visits with RWJBarnabas staffers, mental health opportunities and social services, like food banks, rental assistance and other programs. The program connected one Newark resident, 63-year-old Phyllis — who was caring for several foster children — to purchase the home she had been renting for years, officials said.
“These are short-term quick fixes that can really be put in place and have outsized contributions and can really springboard (an individual’s) ability to be healthy in the long term,” said Ernie Morganstern, the Trenton team’s senior director of population health. “But you can’t do this from an office park in Philly. You need to be able to have that community connection.”
Horizon also created a mitigation fund that could be tapped for uncovered expenses, including the purchase of an air conditioner to help control a patient’s asthma, smoke detectors for homes that lacked them, assistance with drug copays and replacing a broken set of eyeglasses. Resources for the initial pilot came from a portion of the $275 million the company pledged to invest after it received a massive federal tax refund in 2018.
While participation was limited — just 354 individuals were engaged through the Newark pilot — the results were impressive, Horizon said. Since the program launched, the company said it has seen a 24% reduction in emergency room visits among the group, a 35% increase in behavioral care visits, and their cost of care declined by a quarter.
“Our goal was to try and quantify the impact and value this program would have in terms of the health of our members in the program and over the cost of care reduction,” said Allen Karp, Horizon’s executive VP for healthcare management and transformation. ”Our results were great,.”
Karp also said that “the member experience was tremendous. It connected us as an organization with our members and helped them understand that we (as health care payers and providers), instead of working in silos, we were working together.”
Horizon said the first step was identifying the patients with “rising risks” who are most likely to benefit from these interventions in communities around the state. The company’s analytics team worked with assistance from consultants at McKinsey & Company to create a unique formula that considers insurance claims, inputs from commercial marketing firms, and federal census data related to employment status, education level, household makeup and even air quality, officials said.
The insurance giant also worked to establish partners to help launch the program in other communities with great need. In addition to RWJBarnabas, which has hospitals throughout north and central Jersey, Horizon signed agreements with Hackensack Meridian Health, Atlantic Health System, University Hospital in Newark and St. Joseph’s Health, based in Paterson. The insurance company is working with them to hire community health workers and will share the cost of their employment, officials said.
Horizon also connected with the Trenton Health Team to focus on public workers who make up a large share of the individuals the formula identified as “rising risk.” Mercer County has a high percentage of active and retired government employees.
Horizon is covering the full cost for the Trenton team’s contribution.
Effort extends to Camden County
Harr said it is also working to finalize an agreement with the Camden Coalition of Healthcare Providers, which plays a similar role in that county, which will be the 12th county involved in the program. (In addition to Essex, the expansion will target individuals in Hudson, Bergen, Passaic, Sussex, Warren, Morris, Union, Mercer, Monmouth and Ocean.)
“It’s just been tremendous to work with these partners who are connected to the community, who understand the community and who can help us recruit the health workers,” Harr explained. “We were looking for partners that were believers and innovators and were willing to jump into this with us.”
In addition, Horizon tapped Penn Medicine to conduct training for these community health workers — now done online — and technology company NowPow was engaged to provide a single platform to connect all staff involved and track referrals with a system that alerts program officials if patients don’t follow up as indicated.
Velez, with RWJBarnabas, said these are also critical components in the success of an expanded program.
So far, the neighborhood program has hired and trained about 30 of the 60 community health workers Horizon intends to bring on board for the expansion, officials said, and signed up about 100 participants. More than half of these individuals were engaged by the Trenton Health Team and a staff member employed under the contract has also compiled a comprehensive, updated list of local food pantries, pharmacy delivery options and local testing sites in the Trenton area that has become one of the most popular features on its website.
Morganstern, with the Trenton team, said their goals are to connect close to 300 local residents with whatever services or supports they need and to keep them engaged in these efforts for up to six months. He also hopes these individuals experience better health and less negative impact from social determinants.
“You have to look at the data, but you also have to have lived experience,” added THT’s Paulson. “We can’t have a one-size-fits-all solution.”