WHY WE DEVELOPED HORIZON NEIGHBORS IN HEALTH
Horizon Neighbors in Health aims to address impeding Social Determinants of Health (SDoH), the complex, integrated and overlapping social structures and economic systems responsible for most health inequities. The COVID-19 pandemic has made addressing these socioeconomic factors – which include quality of education, physical environment, employment and social support networks – even more critical.
These factors are known to impact clinical outcomes as well as access to health care and are modifiable risk factors. Social distancing measures, which have become a key component of flattening the coronavirus curve, have also highlighted the need for a highly targeted program that reaches out to those communities where resources are needed the most, but currently lacking. Moreover, the health care needs of individuals across New Jersey have changed dramatically and dealing with SDoH requires an ability to adapt to those changes. While traditional care delivery has tried to address SDoH needs, they have been limited by lack of time, skills and community linkages.
HORIZON NEIGHBORS IN HEALTH PARTNERS
HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY MEMBERS across Commercial, Medicaid and Medicare Advantage will be targeted for inclusion.
Who Does It?
60 COMMUNITY HEALTH WORKERS
— who are hired from within the communities they serve — will be hired, trained and certified to conduct telephonic communication.
HOW IT WORKS
Horizon Blue Cross Blue Shield of New Jersey’s social determinants model utilizes community health workers and personal health assistants in order to address critical elements which currently fall outside of the traditional care delivery model.
Penn Medicine provides training through its IMPaCT Training and Certification Program for CHWs, managers, directors and coordinators. This includes:
10 days each year of in-person or virtual CHW training on critical topics;
3 days each year of in-person supervisor training on core skills;
1 day each year of in-person executive education to support the Customer’s leadership;
1 half-day each year of in-person or “virtual” coordinator training to help develop efficient workflows related to patient identification and screening, outreach and enrollment, and evaluation and reporting; and
Initial certification of completion for individuals who successfully demonstrate mastery of core competencies for their role, and certification renewals every three years thereafter.
PILOT PROGRAM: THE NEWARK INITIATIVE
Horizon Neighbors in Health is based off of a 2017 pilot program where Horizon Blue Cross Blue Shield of New Jersey partnered with Robert Wood Johnson Barnabas Health System to address social determinants of health in Newark. For the pilot program, ~1k commercial fully insured high/rising risk members were identified within four zip codes in Newark. These members were provided with support such as referrals to specialty care, education, wellness/preventive screenings, PCP appointment scheduling / follow-ups, face to face and telephonic support. The team connected members to social, community and health care resources in order to mitigate their social barriers.
Traditional Care Delivery
- Limited care coordination
- Limited use of community based resources
- Lack of access to comprehensive member information
- Limited use of analytics
Integrated Care Delivery
- Care coordination across all systems
- Deliberate use of community resources
- Access to clinical outcomes and financial data
- Analytics based insights for identification and course \ correction
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For the engaged population and over the course of 1 year, we achieved approximately:
Ultimately, the goal of Horizon Neighbors in Health is to address social determinants of health barriers that impact social, emotional and physical health, in turn guiding our members through these difficult times and ultimately empowering them to live their best lives through increased availability of options and information. We want this program to serve as a model for the rest of the nation and hopefully expand to include every corner of the state.