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 has made addressing these socioeconomic factors – which include quality of education, physical environment, employment and social support networks – even more critical.

*RWJBH.ORG/WHY-RWJBARNABAS-HEALTH-/SOCIAL-IMPACT/

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 nolonger 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 2,500 people were enrolled in the program in 2020, with 730 having graduated (meaning their program specific needs have been met).

2,588
TOTAL #
ENROLLED
730
TOTAL #
GRADUATED (28%)
TOP NEEDS IDENTIFIED
FINANCIAL STABILITY
FINANCIAL STABILITY
FOOD
FOOD
BASIC HEALTHCARE
BASIC HEALTHCARE

HORIZON NEIGHBORS IN HEALTH PARTNERS

How Many?

24,000

HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY MEMBERS across Commercial, Medicaid and Medicare Advantage will be targeted for inclusion.

How Many

Who Does It?

Up to

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.

TRAINING PROCESS

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

OUTCOMES:

For the engaged population and over the course of 1 year, we achieved approximately:

MEMBER EMPOWERMENT

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.