By Tim Darragh

Posted: July 31, 2013

There’s been quite a bit of behind-the-scenes work going on in Allentown’s ‘”hotspot” program designed to reduce health care costs by flooding health care superutilizers with support.
Now, the Highmark Foundation has stepped in with more behind-the-scenes assistance.
The foundation awarded $141,000 to the Congregations United for Neighborhood Action (CUNA), a local faith-based organization, to use during the next two years for a “community connector” position.
The funds will support the non-clinical component of the initiative, called the Neighborhood Hot Spot program. The community connector will work directly with patients identified through the Lehigh Valley Health Network and other providers as candidates for intensive case management and hands-on support, Highmark said in an annoucement.

“We recognize the best way to break the cycle of over-using hospital services is to understand and address the underlying and oftentimes daily challenges that patients face,” said CUNA Executive Director Joshua Chisholm. “For instance, ensuring pill caddies are pre-filled for sight impaired or coordinating transportation for regular dialysis visits can prevent unnecessary trips to the emergency room and associated medical costs that are felt by the network and broader community.”

The community connector will examine barriers, habits and circumstances that lead individuals to use and overuse the emergency room for health care versus more cost effective and patient-centered care they would receive through a primary care physician, it said. These barriers include lack of social networks, food access and other social determinants of health. Without addressing the barriers super utilizers face, they are likely to return to unsafe and/or unhealthy living conditions, and ultimately once again using emergency service, it said.
“We decided to fund the community connector position because of the commitment that CUNA has demonstrated to making advances in care delivery within its community,” said Rosemary Browne, a program officer for the Highmark Foundation. “We believe that change occurs when health care providers and the community work together to improve quality, capacity and accessibility of health care services to the patient.”
The widely recognized Neighborhood “Hot Spot” model was developed in 2007 in Camden, N.J. by Dr. Jeffrey Brenner, a family medicine physician at Cooper University Hospital, and the Camden Coalition of Healthcare Providers. Looking at Camden-area hospitals’ data, he found that the sickest 1 percent of people there accounted for 30 percent of the area’s health care spending. By targeting those people, the coalition was able to slash health care expenditures.

CUNA and community health officials in Allentown last year started the hotspot program after sharing in a three-year, $14.3 million federal health innovation grant.

By Andrew Kitchenman
Posted July 26, 2013

UnitedHealthcare worked closely with the Camden Coalition of Healthcare Providers to share information and manage care for 16 Medicaid patients in the city.

While the coalition had already facilitated the sharing of information among hospitals, doctors, and other providers in Camden, United was in a position to add information for patients it insures, such as visits made to providers outside the city. This is one of the key ways the partnership differed from earlier attempts.

Another important difference: UnitedHealthcare paid for the aggressive, face-to-face care coordination the coalition is known for.

“The only thing that’s going to work is face-to-face contact . . . to shift resource out of the buildings and out of the cubicles and into the communities,” said Executive Director Dr. Jeffrey Brenner, who also serves as the medical director for the Cooper Health System’s Urban Health Institute.

The results of the partnership proved promising: lower costs and more appointments with primary-care providers.

These results could lay the groundwork for a much larger project that is expected to launch in multiple areas across the state next year — Medicaid accountable care organizations. This project is intended to transform the payment system for healthcare to low-income residents by rewarding providers who deliver high-quality care at lower costs.

The coalition has received national attention for its work in coordinating care and sharing patient information across a wide spectrum of providers in the city]. They’ve used this data in “hot spotting,” targeting services to those neighborhoods where patients have been making the highest number of unscheduled hospital visits.

“They were using that information to identify not only the patients who were the so-called superutilizers, but also the level of care and care coordination” those patients who frequently are hospitalized should receive, said Ernest Monfiletto, United’s vice president of provider network strategy. “It demonstrated to us a level of sophistication” in how to use information.

“We really understood that our objectives and their objectives were in line,” Monfiletto said. “The more we talked about the opportunity of collaborating, the more we saw commonality.”

UnitedHealthcare Community Plan of New Jersey President Scott Waulters concurred, allowing the company to strike a two-stage agreement with the coalition. The community plan manages the care for more than 300,000 Medicaid patients in the state.

For his part, Brenner said he was interested in health plans willing to spend resources in their members’ communities, rather than solely managing care by telephone.

The first stage of the partnership was choosing a select group of UnitedHealthcare’s most frequent hospital users to receive more intensive care-coordination throughout 2012. The company planned to determine whether the experiment was worthwhile by tracking the results and comparing them with the patients’ healthcare use in 2011.

If the project saved money, the savings would be shared with the coalition, which in turn would share them with providers.

While 50 of these patients were identified, only 29 remained eligible for UnitedHealthcare plan membership throughout the two years of the project. Sixteen of these patients agreed to participate.

The coalition began coordinating care for these patients from their first hospitalization in 2012. A coalition care coordinator would meet them at the hospital, discuss their conditions, and help schedule follow-up appointments with primary-care providers. They would also work to ensure that patients then made it to those appointments, helping to arrange transportation, for instance.

“Many of [the patients] have had expensive involvement with the healthcare system,” but that experience hadn’t been interactive, Monfiletto said.

Brenner said it was a challenge to bring the coalition and the health plan’s management models together.

“It took a lot of planning and a lot of midcourse adjustments,” Brenner said, adding that both sides recognized the requirements of the other in measuring performance goals.

After a year, the results were clear and the savings were real, according to both parties. Patients made more visits to primary-care providers and fewer visits to specialists, which lowered the cost of care. In addition, they received fewer prescriptions at a lower total cost, although the prescriptions they did receive had a higher average cost. Perhaps most importantly, the participants had fewer high-cost hospitalizations, although their emergency visits stayed the same.

The healthcare habits of the 13 patients who chose not to have their care coordinated remained unchanged

“To us, what that showed was a movement away from episodic care” toward better-managed care for the project participants, Monfiletto said.

Brenner said the results were “what you would expect” from paying more attention to each patient’s care, leading to fewer unnecessary prescriptions and an improved relationship with primary-care providers.

Now UnitedHealthcare and the coalition are in talks for phase two of the project — a contract that would cover a broader share of the plan’s members in the city. The contract will be based on the regulations that the state has prepared for Medicaid ACOs.

But UnitedHealthcare is not completely satisfied with those regulations. For instance, the ACOs are intended to involve all of the providers in an area, but UnitedHealthcare wants to focus on four that have fully integrated a new approach to care coordination.

“We want to be sure that all of the opportunities for building a foundation for a future will be in place from the start,” Monfiletto said.

Brenner said the contract would fit into the broader ACO framework of community-based collaboration among hospitals, doctors, other care providers, and patients.

The greatest challenge for the coalition is meeting its goal of having primary-care providers who are able to uphold the same level of care coordination that it has been trying to build.

The current primary care model “doesn’t work,” Brenner said, adding that it is based on “meaningless 10- to 15-minutes encounters,” between providers and patients.

Instead, providers need additional well-trained staff members who are able to coordinate patient care.

“You can’t turn the switch on an entire delivery system overnight,” but the UnitedHealthcare contract can be a “perfectly digestible bite,” Brenner said.

He hopes to strike similar contracts with Horizon and other Medicaid managed-care plans.

While the initial stage of this partnership may have been small, it has encouraged Allison DeBlois, executive director of the Affiliated Accountable Care Organizations, an initiative of the nonprofit New Jersey Health Care Quality Institute.

“This is more than just getting people out of the ER and really giving them the primary care and the social services that they need,” she said. “The first phase was more of a trial — I feel like the next phase is the real launch to the ACO.”

DeBlois said the implications of successful care coordination are significant for more than just Medicaid recipients.

“We really believe that is going to show that we can really bend the cost curve,” she said, referring to the national effort to reduce the growth in healthcare spending.

By Samantha Melamed, Philadelphia City Paper

Posted: July 25, 2013

Here’s the problem with health-care revolutions: They don’t always look like much.
There was, for example, no ribbon-cutting outside the cramped rowhouse in Kensington’s Norris Square section, the base camp from which Dr. Barbara Schneider and her team are quietly changing the lives of some of Philadelphia’s poorest and sickest residents. There were no press releases, no touting of technology innovations and no awarding of prestigious grants.
There are, however, results.

For the past year, Schneider’s practice, Care Coordination Services LLC, has been working with chronically ill (and extraordinarily expensive-to-care-for) diabetic patients — patients who’d been hospitalized as often as once a month. One man had been admitted 32 times in 18 months. In the first six months of that work, the number of emergency-room visits went down 33 percent. Inpatient admissions declined by half. The guy admitted for 32 inpatient stays, totaling more than 200 days? He has been hospitalized only once in the past year.

Those are impressive statistics — medical-breakthrough-type statistics — with dramatic impacts on both cost savings and the patients’ quality of life

To read the full story click here

Posted: JULY 22, 2013

Crime, lack of information among root causes of many chronic problems with health in NJ cities.

The health of New Jersey’s urban residents is worse than the health of state residents as a whole – and detailed new report focused on the state’s capital city draws a vivid portrait of the problem and its scope.

A new community health-needs assessment found that if healthcare providers in Trenton are going to successfully treat city residents, they must address daunting social problems including crime and low health literacy.

The assessment was conducted by the Trenton Health Team (THT)], an organization dedicated to coordinating the efforts of the city’s healthcare providers.

The study ranked reducing crime and increasing health literacy as two of the top five healthcare priorities for the city, along with reducing obesity, substance abuse and chronic diseases.

THT Executive Director Dr. Ruth Perry noted that both urban crime (both directly through gunshot victims and indirectly through the pervasive fear it causes in a community) and health literacy (the ability to understand medical information and use it to make decisions) are related to the other health priorities.

The team heard from residents who said “We know we need to exercise, but we don’t feel safe walking in our communities,” Perry said.

Her conclusion: “You see how all of these five priorities are interrelated.”

The 2010 Affordable Care Act mandates that nonprofit hospitals conduct these assessments every three years. The assessments generally include analysis of hospital patient data and participation by local public health experts. This information must then be used to adopt plans to meet the needs of the community.

The amount of time and effort that hospitals commit to the assessments can vary, but officials with Capital Health, which operates Capital Health Regional Medical Center, and St. Francis Medical Center decided to work together in an intensive effort as part of the THT, which also includes Henry J. Austin Health Center and city officials. They were able to take a more comprehensive approach involving dozens of local community organizations, thanks to a grant from the Robert Wood Johnson Foundation.

Perry said the assessment was unique because it looked at the root causes of local health problems, rather than just tallying medical cases.

“If residents are afraid their kids going to get shot, then they’re not going to exercise,” Perry said.

St. Francis executive vice president Christy Stephenson, who codirected the assessment with Perry, said the new study was different from one her hospital conducted in 2010 because there was much more community involvement, including a series of public forums.

“It became clear after the second forum that the issues in Trenton were not confined to diabetes, hypertension, heart disease — it was like peeling an onion and people were talking about the environmental things as well as the social barriers” to achieving improved health, she said.

This led the group to directly ask residents what environmental and social factors affect healthcare.

“Crime and violence came up right away,” Stephenson said. “Many of the parents and grandparents felt that was one of the reasons that obesity was so high.”

The social factors came to the forefront in part because the assessment focused on city residents, rather than looking at the needs of the hospitals’ suburban patients.

“In some ways Mercer County is like the land of the haves and the have-nots,” Stephenson said. “That is very much the case where it comes to crime, violence and health literacy.”

Among non-English-speaking residents, language barriers affected residents’ health literacy, she noted. The assessment noted that 35.4 percent of Trenton residents speak a language other than English at home, higher than the 29.2-percent statewide average.

Perry added that if the THT can address health literacy, it would help residents to take care of themselves.

Dr. Robert Remstein, Capital Health’s vice president for accountable care, said the concerns about health literacy matched his own experience in the city. “If patients don’t have the basic fund of knowledge of what diabetes is,” as well as its complications and symptoms, Remstein said, “we’re not going to get off the dime with those patients and we’re really going to have bad outcomes.”

Remstein said the assessment was eye-opening for him. While he has worked as a doctor in Trenton since completing his residency in 1985, he had always thought of crime as a distinct problem, rather than as a cause of other health problems.

“The impact of where you live and the trauma of poverty around that area directly impacts your health,” he said. “I don’t think I ever realized that as an independent variable that can impact your health.”

He noted that as the THT conducted the assessment, scientific studies were published that linked stress to genetic changes.

Remstein said hospitals have traditionally based community health needs assessments on “the colored glasses of the organization.” Having an assessment that involved multiple hospitals led to a broader perspective.

Perry acknowledged that the THT took on an extremely difficult task by producing an assessment that focuses on major social problems.

“It can make it more difficult to address them, but I think here in Trenton we’re in a unique position” because every health provider, community organization and the city government are united in the effort, she said.

Perry gave another reason – based on economics — for investing in addressing these issues.

“I personally think that this is really key for Trenton because if we cannot get our population healthier and safer, then I think it limits Trenton’s ability to have a renaissance,” Perry said, noting that the chronic diseases that result from these factors affect the city’s workforce. “Businesses will not come if they think the community is not safe.”

The THT has assembled five working groups to look at each of the five priorities listed in the assessment. They will meet over the next two months with a goal of developing a plan to address the needs as soon as late September. Each of the group must develop concrete goals and objectives that can be measured, Perry said.

Stephenson sees the hospitals taking a new approach to addressing community needs as a result of the assessment. Rather than tailoring programs to meet individual diseases as concern about them arises, the hospitals will be able to prioritize their programs to address the larger priorities laid out in the assessment.

“They’re big (and)…audacious goals, but I think we’ll be much more effective not overlapping but working in concert,” she said.

By Jenna Pizzi/The Times of Trenton
July 18, 2013

Yesterday the Trenton Health Team (THT) identified the top health priorities for city residents, and shared its Community Health Needs Assessment (CHNA). The CHNA describes obesity, substance abuse, safety from crime, chronic disease and health literacy as priorities that require community-wide attention and focus.

Our unique CHNA process engaged Trenton residents as collaborators in an unprecedented way, using a combination of quantitative health data and qualitative resident feedback to establish health priorities for the city. In partnership with residents and 29 organizations across Trenton, we created one unified, holistic CHNA for the city rather than a series of separate assessments, each with a limited view.

A press release giving more details about the report and our innovative CHNA process can be accessed by clicking here.

For access to the complete CHNA, please click here. The full report is available for download.

THT will share the CHNA with the Trenton City Council next month, since yesterday’s meeting was rescheduled.

Keep up with THT–subscribe to our blog and connect with us on Facebook

We’ve started a blog which will cover our work in the community of Trenton and occasionally offer commentary on various topics related to community health, healthcare reform and health policy.

Please take a moment to connect with us in one or both of the following ways:

1) Subscribe to our blog: Visit our blog, Trenton Health Team Talks, and enter your email address into the sidebar on the right. You’ll get an email when we post something new.

2) Like the THT Facebook Page: If you are active on Facebook, you’ll see some of our updates in your feed when we write a new blog post or share other health-related information in our status.

In the coming months we will be working on our Community Health Improvement Plan (CHIP) and blogging about our CHNA findings. We hope you’ll keep up with us and join in the conversation!

Thank you for your interest and support as THT works to make Trenton the healthiest city in the state.


Ruth Perry, M.D.
Executive Director
Trenton Health Team

By Trenton Health Team

Posted July 30, 2013

In another collaboration of the City of Trenton and the Trenton Health Team, today we are announcing the creation of a new volunteer healthcare corps to serve uninsured city residents. The first volunteers – physicians, nurse practitioners, registered and licensed practical nurses, physician assistants, health services aides and clerical workers – will staff the Trenton Pediatric and Adolescent Treatment Center. We are hoping to re-open this city clinic, which has been closed since 2008, before the end of summer with the help of the healthcare volunteers.
Volunteers will be asked to devote two to four hours at a time at the clinic, located at 218 North Broad Street, Trenton, NJ. Medical malpractice coverage will be provided to volunteers at no charge as a result of recent federal action granting the city what is called a “free clinic status.” This spring the U.S. Department of Health and Human Services, Health Resources and Services Administration, deemed the city of Trenton’s clinics as free clinics, enabling the city to provide the very expensive malpractice insurance at no charge to practitioners.
Our aim is to open the clinic five days a week, with hours of operation determined by the availability of our volunteer healthcare corps staff. We are hopeful that doctors, nurses, and other professionals who are retired or otherwise available will help us restore this vital city service.
At the re-opened pediatric and adolescent center, a variety of preventive services to keep children from newborn to 17 years of age healthy, such as immunizations children need before starting school in September, will be offered. Other services include well baby visits and physical examinations for children and teens.
Over time we plan to expand services and reopen the adult clinic, providing all primary care services, and to create a specialty care clinic focused on chronic diseases such as diabetes, obesity and high blood pressure.
Healthcare professionals considering volunteering are asking to contact the Health Department at 609-989-3242, ext. 109.

02 July 2013


Imagine an infectious disease was harming 100,000 Americans each year and killing another 30,000. The public health community and government would be mobilized immediately and every resource at our disposal would be used to fight the scourge.

Gun violence kills and injures that many Americans each year. It is indeed an epidemic and the public health community must be part of the solution. We’ve shown that public health measures can reduce the number of Americans killed on our roadways, and reduce the number of children killed by harmful toys and products. We’ve shown that public health measures can reduce the percentage of people who smoke cigarettes.

Yet the gun lobby has thwarted our efforts to use public health research and interventions to stem the lethal gun violence in our schools and streets. A seminar the Quality Institute co-sponsored at Princeton University recently brought together public health experts who described how political pressure has stifled just about every common-sense effort to understand and stem gun violence.

I was among those who spoke at the event we sponsored with the Woodrow Wilson School of Public and International Affairs, The Children’s Hospital of Philadelphia and the Center for Health and Wellbeing. The speakers were smart and compassionate — everyone from emergency room physicians to engineers to social workers in communities hit hard by violence. No one saw gun violence as only a law-enforcement issue.

At one point, though, I wondered if we were merely preaching to the choir. But then I realized, for instance, that nine out of 10 Americans support background checks of gun purchasers. The number comes from a Washington Post-ABC News poll and it mimics every other major poll on the subject. The same poll found that an astonishing 74 percent of NRA members — yes, NRA members — support background checks.

Indeed, America is the choir.

We have allowed gun manufactures and their influence of NRA leadership to thwart common sense measures that most Americans, indeed, even most gun owners, support

At the seminar Gov. James Florio spoke about his experience fighting the NRA in New Jersey to both create and protect the state’s historic ban on assault rifles. His story remains relevant today. Gov. Florio showed how to mobilize teaches, doctors, nurses, clergy, law enforcement and everyday citizens to stand firm against the NRA.

Gun violence is a major public health threat that we can — that we must — battle to save lives, especially among young people. The tragedies in Colorado and Newtown shocked us, of course, but each day teenagers and children are shot and many of them are killed in poverty stricken neighborhoods. One of our speakers said in Philadelphia five people are shot each day.

The Woodrow Wilson School published an article, Forum Examines ‘Epidemic” of Gun Violence As Public Health Issue. By all means read and please share you thoughts. On the issue of gun violence, we need to recognize that the majority of Americans have long ago joined the choir.