Horizon Neighbors in Health
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 continued to make addressing these socioeconomic factors – which include quality of education, physical environment, employment and social support networks – even more critical.
LAUNCHING HORIZON NEIGHBORS IN HEALTH
In the spring of 2020, Horizon Blue Cross Blue Shield of New Jersey set out to launch the state’s, and perhaps the country’s, largest ever program to address Social Determinants of Health. The program, Horizon Neighbors in Health, was created after months of careful thought and collaboration withNew Jersey’s leading health care providers. Horizon Neighbors in Health was meant to provide direct, face-to-face interaction between high-risk Horizon members and community members who could provide the services needed to address Social Determinants of Health.
On the eve of the program’s launch, the COVID-19 outbreak began reshaping our world and day-to-day lives. Face-to-face interaction was simply no longer possible: but at the same time, the pandemic only exacerbated the conditions that create Social Determinants of Health in the first place. With this in mind, Horizon and its partners moved forward with the official launch of Horizon Neighbors in Health in April 2020. The results, even in the face of a global pandemic, have been extraordinary. Over 13,000 people were enrolled in the program through the summer of 2023, with 8,000 having graduated (meaning their program specific needs have been met).
Horizon's Neighbors in Health Helps Support a Mother of 3 Autistic Sons
HORIZON NEIGHBORS IN HEALTH PARTNERS
HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY MEMBERS across Commercial, Medicaid and Medicare Advantage have been helped since 2020.
Who Does It?
60 COMMUNITY HEALTH WORKERS
— who come from within the communities they serve — were hired, trained and certified to engage directly to support members.
HOW IT WORKS
Our 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.
- The Horizon Neighbors in Health Program (HNiH) partners with the Penn Center for Community Health Workers (PCCHW) to train the HNiH Community Health Workers (CHW)
- Includes a 10-day training with class instruction, role play, situational reviews and an opportunity to network and develop a support system with instructors and other CHWs
- Refresher training completed as partner needs are identified
- Hiring algorithm
- Validation of program outcome / performance metrics
- Ongoing support
- COACH Model provides CHWs with techniques for an authentic, healing relationship
- RELATE program instructs CHW leadership on how to support the CHW
- Monthly discussions are facilitated, by the Camden staff, on the model approach using real-life CHW examples
- RELATE focuses on the "Coaching Quartet" - Validation: Identify strengths and affirm, Observation: Note what is being seen and heard, Provide a Rationale: Discuss the "why" of the discussion, Inquire: Pose questions to engage around observation
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
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.