By Thomas Vincz, Public Relations Manager

Three years ago, Phyllis says she felt like she was “on the verge of a nervous breakdown.”

The 62-year-old retired former state worker from Newark was living on a fixed income, dealing with hypertension and taking care of two children who had physical and developmental disabilities. Then she learned that her home was in jeopardy when a bank had foreclosed on the two-family house she shared with another renter.

Access to safe housing is not often discussed in the health care debate. But for Phyllis - and the many New Jerseyans who lack housing or access to transportation, deal with food insecurity, or face other obstacles like these - they can be the biggest barriers to achieving good health. In fact, studies have shown that these so-called social determinants of health (SDOH) can account for as much as 80% of a person’s overall health.

These factors have become even more critical in light of the COVID-19 pandemic. Individuals whose access to services and care was challenging in the best of circumstances, now face even greater challenges.

There have been many attempts to deal with social determinants of health over the years. But those efforts have typically focused on a single issue – nutrition, mental health, housing, education – instead of addressing all the problems contributing to poor health. As a result, they have had limited success.

But now, Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) has launched Horizon Neighbors in Health, the largest, most comprehensive program ever created in New Jersey to address social determinants of health. 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 that make good health more possible.

Phyllis, a retired former state worker, received assistance to address her medical, childcare and housing concerns through an innovative partnership facilitated by Horizon BCBSNJ to address SDOH

 

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

“This demonstration project expands on the pilot Horizon ran with RWJBarnabas Health in Newark in 2017. That pilot provided strong evidence that working together, a health insurer and a health care provider could successfully intervene to address social determinants, improve health, and reduce the total cost of care for an individual,” said Allen Karp, Executive Vice President for Health Care Management and Transformation at Horizon BCBSNJ. “The lessons learned in Newark are being scaled and deployed in multiple communities across New Jersey to engage 24,000 Horizon members over the next three years.”

“Working with our local health care partners, Horizon Neighbors in Health will establish a body of data that we expect will demonstrate both the health and financial benefits of using the University of Pennsylvania’s Community Health Worker model to deliver an individualized intervention connecting our members with resources that address their non-healthcare needs,” added Valerie Harr, who leads the initiative as Horizon BCBSNJ’s Director of Community Health. “Once we understand how those investments impact health and cost, we can scale this further and incorporate this approach into Horizon’s coverage and the work we do administering health plans for self-insured groups.”

Community Health Workers (CHWs), hired by the local health partner with a grant from Horizon and trained by the Penn Center for Community Health Works, engage directly with high and at-risk patients identified by Horizon. 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.

Horizon BCBSNJ and its partners have been working for more than a year to prepare for a Spring 2020 program launch. The COVID-19 pandemic has forced them to make some modifications, but they believe that the work is more important – and more needed – as a result.

“The model was designed to enable CHWs to engage face-to-face through in-home visits. Obviously, that’s not possible so we’ve shifted to engaging over the phone,” said Tracy Parris-Benjamin, Director of Clinical Design, Community Health at Horizon BCBSNJ. “The community health workers are not only helping connect those members with the right social services, they are helping them deal with the added strains and stresses being created by the COVID pandemic.”

Horizon BCBSNJ identifies potential program participants using advanced data analytics that detect those members whose health history indicates an elevated or increasing level of risk for poor health. Horizon BCBSNJ and its local partner organization then reach out to explain the program and its benefits and invite members to participate at no cost.

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.

It is this focus on whole-person care that makes Horizon Neighbors in Health different than previous efforts to address SDOH.

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 is also focused on members who live in places like Toms River, Keansburg, Morristown, and Denville.

Harr, who ran New Jersey’s Medicaid program prior to joining Horizon BCBSNJ three years ago, says that Horizon Neighbors in Health represents a new reality and a new way of looking at health.

“Our goal is to help our members – all of them - achieve their best health,” Harr said. “We know that social, economic, emotional, and mental factors have an enormous impact on all of us. That impact hits hardest people with chronic health problems or whose lives suffer from lack of good food, housing, mental health support, education, or employment opportunities. Horizon Neighbors in Health is stepping in to fill a very significant gap to connect the social services and health care systems in a way that makes it easy for our members to get what they need in order to get and remain healthy. We are going to change health care in New Jersey in a very significant and positive way.”

Harr says she hopes everyone ends up like Phyllis. With support from her CHW, Phyllis got her hypertension under control, received assistance with her child-care needs, and connected with a local housing agency that helped her arrange for a mortgage that allowed her to buy that two-family home and become a first-time homeowner.

Phyllis declined assistance the first time she was contacted, but looking back she says she’s glad Horizon BCBSNJ kept trying, “At first, I was afraid to ask for help. But sometimes, you just need to find the courage to speak to someone. I didn’t know my health insurance provider could help me with my housing situation. But I’m sure glad they did.”

To learn more about Horizon Neighbors in Health, visit www.horizonhealthnews.com/horizon-neighbors-in-health/.