As an RN who for years traveled from the stark tenements of Newark to the elegant homes of Rumson to deliver care to patients, Clare Mooney knows the character and contours of virtually every New Jersey neighborhood. For this reason alone, Clare seems fit for her role at Horizon – which is implementation manager for Horizon Neighbors in Health (NiH). The NiH program is a “boots on the ground” approach to helping New Jerseyans overcome barriers that get in the way of their health. The obstacles can be many, and can be in someone’s home or in their neighborhood. Clare and her team find solutions that are both simple and complex, but that work because of one universal ingredient: the power of the human touch.

The Human Connection

Clare entered nursing in the early 1990s working the medical-surgical floors at Jersey Shore Medical – “THE hardest job in nursing” she says, and Labor and Delivery. Next, she became a visiting nurse, logging some 35,000 miles a year on her car traveling “across the length and breadth of New Jersey.” Charged with delivering care at home to women with high-risk pregnancies, she recalls marveling at patient data showing that patients treated at home did just as well as high-risk patients treated in – and with all the resources of – a hospital.

But knowing what she now knows, she understands why. “The women were doing well at home not only because of the medication or treatment they were receiving; they were doing well because they had a human connection – the visiting nurse.” 

As that connector, Clare delivered both care and companionship. Many of her patients were homebound or lived in areas far removed from grocery stores and other necessities. She saw firsthand how important it was to the health of moms and babies to make connections to community-based social support resources.  

The Well-Travelled Road to Horizon

After visiting patients at home for years, Clare found her home at Horizon. She joined a team that worked with doctors and hospitals on ways to improve patient care. But in 2018, Clare returned to her community roots. She asked to work on “The Newark Initiative” – a unique program that Horizon piloted with RWJBarnabas Health to diagnose and fix the non-medical factors in a person’s life that were sabotaging their health. Clare took over the reins of that program where she supervised community, health and social workers in the field who visited Newark homes and connected patients to local resources and benefits. Because of this intervention and personalized attention, Horizon members could concentrate on their health instead of stressing over their next meal, finding a ride to a specialist, or making the rent payment on time.

Before the Newark Initiative ended, Clare was already making the case to her manager to build out and expand the program statewide.

“Clare has passion and many talents but her true strength is taking concepts and operationalizing them, and that ability is rare,” said Tracy Parris-Benjamin director of Clinical Design in Horizon’s Community Health Division, and Clare’s supervisor. “Clare is also an equity champion. She promotes health equity and challenges everyone to think more thoughtfully about the reasons why some individuals struggle to get the care they need to be healthy. These qualities have served Clare extremely well.”

Meeting Patient Needs from Every Angle

The Horizon Neighbors in Health program helps up to 25,000 Horizon members overcome their obstacles to a healthy lifestyle. NiH is supported by Horizon and 11 partner organizations and deploys about 50 specially trained Community Health Workers (CHWs) to work 1-on-1 with clients. The program’s success depends on trust. The clients rely on the support of CHWs; the CHWs rely on the support of their Health system, and the Health systems rely on Clare to make sure clients are making progress to their goals.    

“My colleagues and I meet with health system managers and coordinators weekly or biweekly, and CHWs daily with standing meetings,” Clare noted. “These meetings and huddles keep us all on the same page and provide the opportunity for subject matter experts to look at the members’ needs from every angle.”

The partners agree, and appreciate Clare’s bottom-up management style.

“Clare has always been able to roll up her sleeves and dig in with the team to help find solutions to some of the challenges we are facing,” said Kimberly Birdsall, MPH, Executive Director of the Health Coalition of Passaic County, a program partner with St. Joseph’s Health. “We can see how committed she is to this work and we are honored to work with her and Horizon on this project,” she said.

“Clare takes the time to understand the unique needs of the Atlantic City community we serve,” said Samantha Kiley, MPH, MBA, executive director, Community Health Advancement and Development, AtlantiCare. “The keen insight and clinical experience she brings to our shared work is helping us to solve for the broader social barriers that can impede care.”

“Clare is a project manager who brings the knowledge and compassion of a nurse to her work,” added Jessica Czepiel RN, BSN, of Inspira Health Network. “She’s receptive to providing resources that our CHWs may not know about and follows through on her commitments to the team.”

What’s At Stake

Clare wears the “thinking out of the box” label as a badge of honor. She worked with her supervisor and colleagues to create NiH through a series of whiteboard sessions, and she’s more confident than ever that it will “change the trajectory of lives.”

 “I was raised to believe we have the responsibility to leave the world at least a little better than when we found it, and this is a program that makes that possible. We’re all better when everyone has a chance to be healthier,” she said.