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NJ’s Largest-Ever Program to Tackle Social Determinants of Health Succeeds in Time of Uncertainty


For thousands of New Jerseyans living through the pandemic’s cruelties, the groundbreaking Horizon Neighbors in Health program offers a lifeline to a healthier future. See how.


Thomas Vincz head shot

By Thomas Vincz, Public Relations Manager

As COVID-19 began reshaping our everyday lives, Jay was already struggling to maintain hers.

She has tried for years to provide her three autistic sons with a quality education but often runs into issues with her school district. Once the pandemic hit, she was providing at-home schooling to all three, from language arts to math to functional living skills. Because of the different ages of her children, she had to teach at different levels of learning. Jay herself has struggled with chronic nerve pain for years while also dealing with seizures and stress-induced pain.

There are thousands of New Jerseyans like Jay, struggling to deal with daily issues – from schooling and feeding their children to maintaining their own mental and physical health – which were difficult before COVID-19. For them, the pandemic has been especially cruel.

For Jay, a new program from Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) has been a lifeline. The program, Horizon Neighbors in Health, aims to tackle the social determinants of health (SDOH) – issues such as lack of housing, access to transportation, or food insecurity – that can be the biggest barriers to achieving good health, but that have long been outside the reach of traditional health care.

Partnering to improve New Jersey’s health

Launched in the spring of 2020 at the height of the pandemic, Horizon Neighbors in Health is the largest, most comprehensive program ever created in New Jersey to address social determinants of health. Horizon BCBSNJ, the state’s largest health insurer, is investing $25 million and partnering with some of New Jersey’s most respected health organizations over the next three years on a model that employs local Community Health Workers to connect members with a wide array of services to address challenges hampering their health and well-being.

Health organizations working with Horizon BCBSNJ include Atlantic Health Systems, Hackensack Meridian Health, RWJ Barnabas Health, Trenton Health Team, University Hospital, St. Joseph’s Health and the Camden Coalition.

Community care that goes beyond health insurer’s traditional role

Community Health Workers (CHWs), hired by the local health partner with a grant from Horizon and trained by the Penn Center for Community Health Workers, engage directly with patients identified by Horizon BCBSNJ as being at-risk for poor health outcomes. CHWs come from the communities where they will be working, a critical factor that, according to the Penn Center, helps build trust and understanding with the individuals the program aims to serve.

The CHWs undergo two weeks of training from the Penn Center. They learn how to work with their patients, identify their needs, connect them with services, and provide information that helps members improve their own understanding of health and how to use their insurance benefits to achieve their personal health goals.

CHWs use NowPow, an online platform that maintains an up-to-date inventory of services available from local social, non-profit and community service organizations. The platform enables the CHW to connect members to needed services, track utilization, document outcomes, and ensure participants are getting the assistance they need.

That training, coupled with CHWs’ intimate knowledge of their community and immediate surroundings, is already assisting those in the program. Cheryl Towns BSN, RN, a Nurse Care Manager for Trenton Health Team Care Management Team, has been able to help Jay deal with a variety of issues. Cheryl sees Horizon Neighbors in Health as vital in finding and assisting people who might not otherwise be looking for, or willing to accept, help.

“We have been able to feed countless families, pay for prescriptions, even help get someone a laptop so they can enroll in classes to start school,” said Cheryl. “And the first thing they say is, ‘Through my insurance company? I've never heard of that. This must be a scam.’ No, it's not a scam. It's that your insurance company cares for you, the member.”

Cheryl reached out to Jay, who was initially hesitant to engage. Jay had told her story to people before only to hear they could not help her. Cheryl did not want to be the next person to tell her sorry.

“I pulled up to her house and got her a month, two months’ supply of diapers for one of her kids. We were also able to give her a $200 gift card from ShopRite.”

Making a difference for thousands of members across 70 zip codes

For Jay, the program has helped provide some stability during uncertain times. Cheryl has helped her locate community resources to help with academics and recreational activities for her children.

“Cheryl, in the midst of this whole big storm, has been a breath of fresh air,” said Jay. “She was my lifeline. It’s like when you’re in a cave and you see this glimmer of light. I didn't have to wait. I didn't have to check in with her. She kept checking in with me. She continues to check in with me and she's just been a blessing because she's taken a little bit off my plate, which I can always use less on my plate.”

Horizon BCBSNJ’s Personal Health Assistant (PHA), Leigh Santorelli, served as the first point of contact to Jay, engaging in an empathetic dialogue regarding the impact of the pandemic on her family and the challenges she was experiencing. Following an in-depth conversation that enabled Jay to share her need for support, the PHA referred Jay to the NIH Trenton Health Team Program. Leigh and Cheryl worked together to ensure Jay’s basic and medical needs were addressed. Leigh identified and coordinated her medical appointments and connected with a Horizon BCBSNJ Care Manager. Leigh and the Care Manager are working together to identify a medical provider who will address Jay’s long-standing chronic pain concerns. 

Through the PHA, Jay’s children also were enrolled in care management programs to assist with care coordination, alleviating some of the stress Jay was experiencing. A relationship was fostered among this collaborative team, with ongoing conversations reinforcing the importance of wellness visits and vaccines to keep Jay and her family healthy. This program continues to provide Jay with the tools needed to seek improvements for her and her families’ emotional and physical health.

The Horizon Neighbors in Health demonstration project will engage members living in 70 zip codes across 11 counties (Bergen, Essex, Hudson, Mercer, Monmouth, Morris, Ocean, Passaic, Sussex, Union and Warren). Besides some of New Jersey’s biggest cities – Newark, Jersey City, Paterson and Trenton – the program also is focused on members who live in places such as Toms River, Keansburg, Morristown, and Denville.

Since kicking off in the spring, Horizon Neighbors in Health has enrolled 1,587 members and currently employees 36 CHWs. Stories like Jay’s are emerging every week, as members use the program to help with issues ranging from medication and food, to business loans and educational needs.

Horizon BCBSNJ ultimately hopes that Horizon Neighbors in Health will serve as a model for the rest of the nation while expanding to every corner of New Jersey. That’s a notion Jay supports. “Whoever created this program, God bless them,” said Jay. “It should be offered across the board.”