By Mary Ann Christopher, MSN, RN, FAAN
Vice President, Community Health

Feeling panicky and desperate, Phyllis didn’t know where to turn for help.

“I felt like I was having a nervous breakdown,” recalled Phyllis, age 63, a retired administrative assistant who raises three foster children in the South Ward of Newark. “I thought I was going to be without a home.”

Newark Initiative participant Phyllis speaks with a Horizon BCBSNJ care specialist in her home. The Newark Initiative helped Phyllis secure housing after her landlord faced financial difficulties.

Having rented the home she lived in for the last decade, Phyllis was unaware that her landlord had failed to keep up with mortgage payments. After the bank began foreclosure proceedings, she and her family were at risk of being evicted … and soon.

Already managing some challenges to her health, Phyllis was frantically seeking help. Then she remembered Tarloh Mouphouet. And she made a call that literally changed her life.

Reaching out to at-risk members

Tarloh is a personal health assistant with the Newark Initiative, a pilot program launched two years ago by Horizon BCBSNJ and Newark Beth Israel Medical Center, an RWJBarnabas Health facility, in four Newark zip codes. She is part of a joint multi-person team of Horizon Personal Health Assistants and Newark Beth Israel Community Health Workers who work in collaboration to connect with residents and address what health care professionals now call the “social determinants of health” (SDOH)— conditions within the places that people live and work. Social determinants of health have a huge impact on a person’s overall health. In fact, recent New Jersey-based research has revealed SDOH can account for more than 60 percent of a person’s health status.

“Good health shouldn’t depend on your zip code,” said Kevin Conlin, Horizon’s Chief Executive Officer. “We know from census and claims data that residents of some areas have a greater likelihood of significant health issues than residents of other areas. We use this information to identify and remove barriers to good care, to get members connected to the right care, and to more effectively deploy the resources and tools they need to manage their health.”

“At Newark Beth Israel our mission goes beyond providing excellent patient care to treat episodic illness. The Newark Initiative is just one of the many programs that we have established to address social determinants of health, empower local residents, and have a lasting impact on the health of our community,” added Darrell K. Terry, Sr., MHA, MPH, FACHE, President and Chief Executive Officer, Newark Beth Israel Medical Center and Children’s Hospital of New Jersey.

At the Rev. Dr. Ronald B. Christian Community Health & Wellness Center in Newark, operated by RWJBarnabas Health, Horizon BCBSNJ members who are part of the Newark Initiative can receive help to address housing challenges, food insecurity and job assistance.

That’s exactly why Tarloh called Phyllis a few months earlier, as part of her Newark Initiative role to proactively contact members who are at high-risk for health problems. Phyllis declined assistance during that initial call, but this time she was ready: “At first, I was afraid to ask for help. But sometimes, you just need to find the courage to speak to someone.”

Going Beyond Health Care to Achieve Good Health

A Newark Beth Israel Community Health Worker who is part of the Newark Initiative care team quickly realized that helping Phyllis with her housing problem would be a key step in restoring her health. Within a few weeks, the Community Health Worker steered Phyllis to a housing support program that explained what federal and state resources were available to her and helped her realize that instead of being a renter, Phyllis had the means to become a home owner.

Today, Phyllis has been pre-approved for a mortgage, is negotiating to buy the home she’s currently renting, and is working with a real estate agent to explore other housing possibilities.

The Newark Initiative Care Team – composed of Horizon BCBSNJ and RWJBarnabas Health specialists – is discussing their daily casework at the center.

Perhaps most importantly, her hypertension and nervousness have disappeared. As Phyllis happily told us during a recent visit, “I didn’t know my health insurance provider could help me with my housing situation. But I’m sure glad they did.”

According to Clare Mooney, a Horizon registered nurse who works with the program, the assistance provided to Phyllis “is a perfect example of how we can empower someone to live the best life possible. That’s the real goal of the Newark Initiative and it goes beyond healthcare.”

“The Newark Initiative provided a unique opportunity for us to partner with Horizon BCBSNJ and pilot a provider and payer collaboration in a way that benefits the community,” added Jennifer G. Velez, Executive Vice President, Community and Behavioral Health, RWJBarnabas Health. “The community health workers were an important part of this collaborative model to address the social determinants of health: those non-clinical issues that ultimately impact patients’ outcomes.”

Wellness – and quality of life – on the rise

According to U.S. Census data, more than a third of South Ward residents live in poverty – a key reason why chronic health problems are also more prevalent there. Diving deeply into medical claims data, Horizon and Newark Beth Israel determined that many residents in the South Ward either had no primary care physician, or failed to use one regularly. When ill, they would typically visit the emergency room, which is not the optimal setting for managing chronic care. Plus, trips to the emergency room resulted in higher out-of-pocket costs for members like Phyllis and a higher overall cost of care that impacts everyone who pays a health insurance premium.

“The community health workers were selected for their empathy and connection to the community, and they received extensive training to maximize their work outcomes with members,” added Rashmi Aggarwal, APNC, AVP Clinical Integration, Newark Beth Israel Medical Center and Children’s Hospital of New Jersey. “They have received training in diabetes prevention education, motivational interviewing, Adverse Childhood Experiences screening and chronic disease management training.”

Since 2017, results from the Newark Initiative pilot have shown that the program is working to expand access to care, improve quality and lower costs.

Several residents infrequently visit physicians because they lack transportation or access to child care. As a result, many chronic conditions go untreated.

By focusing on unmet healthcare and social needs in the South Ward, we felt we could further our longstanding mission of expanding access to care, improving health care quality and lowering costs— and it’s working.

Since embarking on the Newark Initiative pilot in 2017, Horizon and Newark Beth Israel have seen a dramatic improvement in the South Ward: 24 percent fewer emergency room visits, 25 percent lower total cost of care and 35 percent increase in behavioral health visits. This has prompted Horizon to embark on a significant expansion in 2019 with other healthcare providers.

Importantly, the Newark Initiative is making a dramatic impact on quality of life for Horizon members in those four critical zip codes.

While the Newark Initiative team assisted Phyllis in addressing her housing concerns, they also helped her navigate through the healthcare system. At Tarloh’s urging and guidance, Phyllis has now established a relationship with a primary care physician, is up to date on her check-ups, and is more aware of the benefits provided through her Horizon plan.

“I really find this job rewarding,” explained Tarloh, “because we get the opportunity to truly connect with members on a personal level. When we get their trust, we can really help them.”

Phyllis can attest to that. “Once everything was going against me, and now it’s all going for me. When you ask for help, you can learn to help yourself. And that’s the best feeling in the world.”