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Policy Innovation Profile

Citywide Collaborative Implements Multiple Initiatives That Reduce Appointment Wait Times, Readmissions, and Emergency Department Use for Low-Income Minority Patients


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Snapshot

Summary

The Trenton Health Team is a not-for-profit, public–private partnership dedicated to expanding access to high-quality, coordinated care for vulnerable residents in Trenton, NJ. Governed by leaders of its four partner provider organizations plus community representatives, and run by an executive director and staff with input from a community advisory board, the collaborative has implemented multiple community-wide initiatives. These initiatives include having partner-run clinics manage their schedules to facilitate same-day appointments, opening a free clinic for uninsured children and teens, implementing targeted interventions for sickle cell anemia and substance abuse patients, and launching several programs to improve coordination of care. The collaborative is currently developing a health information exchange to facilitate data sharing and population health management, and will be applying to participate in New Jersey’s Medicaid Accountable Care Organization demonstration project (created by recent State legislation). Through its various initiatives, the collaborative has significantly cut the wait times for appointments, enhanced patient–provider continuity, and reduced readmissions and emergency department use.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key outcomes measures, including appointment wait times, readmissions, and ED use.
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Developing Organizations

Capital Health; City of Trenton Department of Health and Human Services; Henry J. Austin Health Center; St. Francis Medical Center
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Date First Implemented

2010
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Patient Population

Vulnerable Populations > Impoverished; Insurance Status > Medicaid; Uninsured; Vulnerable Populations > Urban populationsend pp

Problem Addressed

Low-income, minority residents of urban areas commonly suffer from chronic conditions such as hypertension, diabetes, obesity, and substance abuse. Because the existing medical infrastructure in these areas tends to be highly fragmented, patients have limited access to care, and care is poorly coordinated. As a result, they often do not get appropriate treatment, followup care, or referrals, and frequently end up seeking care in the emergency department (ED) or being admitted to the hospital. While community-based coalitions can help address these problems, such coalitions seldom exist in these areas.
  • Many health challenges for poor urban residents: Low-income urban residents tend to have poorer health outcomes and higher mortality rates than does the general population, largely because of a higher prevalence of chronic diseases.1,2 In Trenton (one of the poorest cities in New Jersey, with a 2011 per capita income of $14,621), 52 percent of residents are African American and 30 percent are Hispanic/Latino. Nearly 4 in 10 residents (39 percent) are obese, nearly a third (31 percent) have hypertension, and 16 percent have diabetes. A community health needs assessment in Trenton identified many critical health issues, including diabetes, hypertension, cardiovascular disease, sickle cell anemia, substance abuse, and behavioral health challenges. Many of the neediest (and costliest) patients in the city have multiple chronic health conditions and little support in ensuring that their treatment regimens are properly maintained.
  • Exacerbated by poor access and lack of coordination: Challenges to health care in urban settings include populations with highly complex medical issues, lengthy waits for appointments, lack of care coordination and service integration, rushed practitioners who do not see the same patients consistently, excessive ED visits and hospitalizations due to lack of primary care and followup, and inadequate self-management training for patients.3 A 2006 study found that only 52 percent of Trenton residents had visited a primary care physician; as a result, Trenton residents were 54 percent more likely to use the ED and nearly 40 percent more likely to be hospitalized than the average American, with many being readmitted frequently as a result of inadequate followup care.4
  • Unrealized potential of community-based coalitions: Urban-based community coalitions that focus on access to coordinated care have been able to improve quality and reduce readmissions among low-income individuals.5,6 However, relatively few such coalitions exist.6

What They Did

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Description of the Innovative Activity

The Trenton Health Team (THT) is a not-for-profit, public–private partnership dedicated to expanding access to high-quality, coordinated care for vulnerable residents. Governed by leaders of its four partner provider organizations plus community representatives, and run by an executive director and staff with input from a community advisory board, the collaborative has implemented multiple community-wide initiatives. These initiatives include having partner-run clinics manage their schedules to facilitate same-day appointments, opening a free clinic for uninsured children and teens, implementing targeted interventions for sickle cell anemia and substance abuse patients, and launching several programs to improve coordination of care. The collaborative is currently developing a health information exchange (HIE), and will be applying to participate in New Jersey’s Medicaid Accountable Care Organization (ACO) demonstration project. Key components of THT are outlined below:
  • Public–private partnership: The Trenton Health Team is a not-for-profit, public–private partnership including Trenton’s four largest health care organizations: Capital Health (which operates Capital Health Regional Medical Center), St. Francis Medical Center, Henry J. Austin Health Center (the city’s three-site, federally qualified health center), and the City of Trenton Department of Health and Human Services (which runs community-based clinics in the city).
  • Joint governance, with input from advisory board: As detailed below, THT is governed by an executive committee and board of directors, with input from established board committees and a community advisory board.
    • Executive committee: This six-member committee meets every other week to discuss strategic and operational issues. It includes Capital Health’s Vice President for Accountable Care and Ambulatory Care, who serves as THT’s President; the City of Trenton’s Director of Health and Human Services, who serves as Vice President; Henry J. Austin’s Chief Medical Officer, who serves as Secretary; St. Francis’s Vice President for Ambulatory Services, who serves as Treasurer; THT’s full-time Executive Director; and THT's Deputy Director of Programs and Operations.
    • Board of directors: The 12-member board provides operational oversight and strategic direction and will soon become more involved in strategic planning. Board members include the four THT officers on the executive committee, other individuals from the partner organizations, and representatives from community-based organizations, including social service agencies, behavioral health organizations, community advocacy groups, and academia. The board will soon be expanding to include additional community representation.
    • Community advisory board: THT leaders regularly receive input from a 40-member community advisory board that includes representatives from local, county, and State government; local colleges and universities; behavioral health and social service organizations; businesses; and faith-based organizations. The board initially provided input as part of a formal assessment of the health needs and challenges within the local community, including suggesting potential strategies to address them. The board meets quarterly to highlight health challenges and offer input on strategic initiatives.
  • Community-wide initiatives to enhance access to care: In partnership with community-based providers, THT has implemented several community-wide initiatives to expand access to care, as outlined below:
    • Open slots for same-day appointments: THT partners use a model known as "advanced access scheduling"7 in outpatient clinics to reduce wait times for appointments and promote more consistent physician–patient relationships. Under this approach, clinics manage their schedules to accommodate a calculated number of same-day appointments that can be anticipated for urgent needs. As part of the model, patients are assigned to a designated physician or provider team, which helps physicians manage patient demand and ensures continuity of care for patients.
    • Clinic for uninsured children and teens: THT helped the city health department apply for and receive "Free Clinic" certification from the Health Resources and Services Administration for its Pediatric and Adolescent Treatment Center, which had closed in 2008 due to a lack of funding. After receiving this certification, the clinic reopened in 2013 and now provides free care to uninsured children and teens by using a staff of volunteer doctors, physician assistants, nurse practitioners, and nurses, who receive free malpractice coverage in return. City health department leaders plan to expand the clinic to provide primary and specialty care for adults.
    • Substance abuse screening and treatment: THT partners are implementing the Screening, Brief Intervention, and Referral to Treatment (SBIRT)8 intervention community-wide, during primary care clinic visits and in the emergency rooms for noncritical cases. SBIRT involves screening patients for drug and alcohol addiction and using motivational counseling to encourage patients with addiction problems to pursue treatment.
    • Sickle cell anemia medical home: A data analysis in 2010 revealed that 167 sickle cell patients visited Trenton emergency rooms 857 times, with 18 "high utilizers" making 624 of those visits. A small pilot with five high-utilizing sickle cell patients in 2011–2012 led to the citywide adoption of a sickle cell treatment protocol developed by a specialist at Capital Health. Central to the protocol is assignment to a primary care medical home. Also included are quadrants of care, including educating patients and families, managing the disease, controlling other conditions such as asthma, and managing crises.
  • Infrastructure to improve coordination of care: THT has developed several initiatives to bolster coordination of care and reduce ED visits, particularly among frequent ED users.
    • Community-wide clinical care coordination team (C4T): The 25-member C4T includes physicians, case managers, nurses, and social workers from the four THT provider partners, along with representatives from community behavioral health and social service agencies. C4T meets monthly to review particular cases, share best practices, and develop joint solutions to improve service and outcomes and reduce costs. For example, the team conducted data analyses to identify the most frequent users of the city's three EDs, and then referred 45 of these individuals to a nurse-led care management team (as described in more detail below). In another C4T initiative, ED social workers refer high-utilizing substance abusers, many of whom are homeless, to community housing programs and substance abuse treatment providers. C4T has also created task forces to tackle specific conditions and challenges, such as sickle cell anemia (resulting in the pilot program described above), behavioral health, and medically high-risk patients.
    • Nurse-led care management team: A four-member care management team (a nurse case manager, social worker, and two community health workers) focuses on supporting and educating Trenton’s most frequent ED users. Employed full time by THT, the team currently works with 45 patients, connecting them to primary and specialty care providers and social services, arranging home visits from nurses and community volunteers, and following up to ensure that they received needed services and adhere to prescribed treatment regimens.
  • Ongoing creation of HIE system: THT contracted with CareEvolution, a Michigan-based information technology company, to build a community-wide HIE system that will provide online, real-time access to shared patient data so that Trenton health care providers can see the detailed medical history of any patient they treat. Once the system is up and running (likely by the end of 2013), providers will be able to view laboratory and radiology reports, ED records, medication lists, and inpatient discharge information. In addition, the HIE system will be used to track data related to population health and the social determinants of health, which in turn will inform the development of new THT initiatives.
  • Planned development of Medicaid ACO: THT is building the infrastructure to become a Medicaid ACO, as authorized by New Jersey legislation (P.L. 2011 c. 114 S2443 4R) passed by the State legislature and signed into law in 2011. This legislation authorizes a 3-year demonstration project in which community-based, nonprofit coalitions can apply to become Medicaid ACOs. Applicants must meet the following requirements: cover all Medicaid beneficiaries in a defined geographic service area; include participation by all acute care hospitals, 75 percent of primary care providers, and two behavioral health providers in that area; and have two community residents on the board of the ACO. Participants will continue receiving their usual Medicaid payments and will also be eligible to receive shared-savings payments that can be distributed to participating providers. The State will release the final ACO regulations at the end of 2013. At that time, THT will apply to participate.

Context of the Innovation

THT is a public–private, community-wide partnership dedicated to expanding access to high-quality, coordinated health care in Trenton, NJ. The impetus for this program came in 2005, when Capital Health announced its intention to close one of its two Trenton hospitals and move it to the suburbs. In response, Trenton Mayor Douglas Palmer convened leaders from Capital Health, St. Francis Medical Center, Henry J. Austin Health Center, and the City of Trenton Department of Health and Human Services to discuss the implications of the hospital closure for residents and strategies to mitigate any negative impact. At that time, the Mayor also commissioned the Katz Consulting Group to conduct a community health needs assessment and develop a plan to improve the status of Trenton’s health and health care services. As its primary recommendation, the consulting group suggested that the four health care service organizations form a formal collaborative partnership.

Did It Work?

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Results

Through its various initiatives, the collaborative has significantly cut wait times for appointments, enhanced patient–provider continuity, and reduced readmissions and ED use.
  • Shorter wait for appointments, enhanced patient–provider continuity: The advanced access scheduling system has significantly reduced wait times for appointments and enhanced patient–provider continuity. For example, wait times at Henry J. Austin’s clinics fell from 37 days to 2 days. At St. Francis Medical Center, 99 percent of patients now receive care from their designated physician or a member of their designated care team. Prior to implementation of this program, these patients did not have a designated provider team and seldom received care from the same provider more than once.
  • Fewer readmissions: The programs focused on coordination of care helped to reduce readmissions within 30 days of discharge in Mercer County by 6.8 percent between the beginning of 2011 and the middle of 2012.
  • Less ED use: C4T activities have resulted in reductions of ED use by more than 45 percent across the city. The aforementioned sickle cell medical home pilot program reduced ED visits by the five participating patients by 33 percent (from 216 visits in the year prior to enrollment to 145 visits in the year after enrollment), saving more than $227,000. The C4T program in which ED social workers refer high-utilizing substance abusers to housing programs and providers reduced use of the Capital Health ED by 61.1 percent and the St. Francis Medical Center ED by 30.3 percent. Both hospitals expect further reductions in ED use in the future.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key outcomes measures, including appointment wait times, readmissions, and ED use.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Building partner trust during monthly meetings: For approximately 4 years after the needs assessment, representatives from the four organizations met monthly to discuss the consulting group’s recommendations, develop strategies, and build trust. Over time, leaders of the former competitors became more comfortable with the idea of collaborating on initiatives focused on the shared mission of improving the health of the community.
  • Forming THT, applying for charitable status: In 2010, the partners created THT and applied to become a New Jersey charity.
  • Obtaining State funds: Also in 2010, the city’s Deputy Commissioner of Heath secured State funding to create the governance infrastructure for THT and to begin pursuing the development of the HIE system.
  • Hiring executive director and staff: In April 2011, THT hired its executive director. A subsequent grant from the Nicholson Foundation enabled THT to hire additional dedicated full-time staff.
  • Implementing advanced access scheduling: THT received a $350,000 grant from the Nicholson Foundation that enabled it to hire a physician practice consultant (Mark Murray, MD) to implement the advanced access scheduling model in Trenton. (Dr. Murray created the model.) During implementation, THT partners designed their own processes for transitioning to the system. The typical approach involved analyzing patient data to determine the optimal patient panel size for each physician and developing a strategy for working down the “backlog” of appointments that were already scheduled. For example, providers at Henry J. Austin centers worked an extra hour each day until the backlog was eliminated.
  • Developing HIE system: The Nicholson Foundation Grant also enabled THT to hire a vendor to create the HIE system.
  • Conducting community health assessment and developing improvement plan: In 2011, THT received a grant from the Robert Wood Johnson Foundation to fund a unified assessment of community health needs. As part of this assessment, THT analyzed 3 years of retrospective inpatient and outpatient data. THT also created the community advisory board as a vehicle to get input from the community and had professional interviewers (under contract with THT) host 30 forums and conduct more than 300 one-on-one interviews with residents in places of worship and community facilities. During these sessions, interviewers focused on identifying the most significant health challenges facing residents, including the biggest barriers to accessing care. A community health improvement plan for the city is currently being developed based on the findings from this assessment.
  • Developing ACO components: As noted, THT is in the process of assembling all necessary components to meet State requirements for participating in the Medicaid ACO demonstration project.

Resources Used and Skills Needed

  • Staffing: THT has an 11-member staff, including an executive director, a deputy director, a director of development, a tuberculosis nurse case manager, a substance abuse program coordinator, a four-member care management team (consisting of a nurse case manager, licensed social worker, and two community health workers), a data analyst, and an administrative assistant.
  • Costs: Data on annual program costs are unavailable.
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Funding Sources

Robert Wood Johnson Foundation; Capital Health; St. Francis Medical Center; Henry J. Austin Health Center; City of Trenton Department of Health and Human Services; Nicholson Foundation; State of New Jersey
The four THT partners contribute funding and in-kind services. In addition, THT has received $10 million in grants since its inception. Grants have come from the Nicholson Foundation ($1.6 million), the U.S. Centers for Disease Control and Prevention, the State of New Jersey, Mercer County (NJ), the Horizon Foundation for New Jersey, and New Jersey Health Initiatives, a statewide grant-making program within the Robert Wood Johnson Foundation.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Allow time to build trust among partners: Adopters should ensure that senior leaders within each partner organization participate in partnership development activities, as time spent in meetings will allow these individuals to build rapport and trust. Once some level of trust has been established, leaders should be encouraged to partner on small initiatives and should be regularly reminded that collaboration is necessary to meet community needs in the context of scarce resources. Over time, these leaders will align around shared priorities, vision, and goals, and will communicate the need for alignment throughout their organizations.
  • Obtain partner commitment for time and financial resources: Outside grants may provide specific programmatic funding, but initial support (both time and money) is needed from the partners to build the organization’s governance infrastructure.
  • Be inclusive: It is important to include all community stakeholders during program development, as the various perspectives they provide will ensure that the program is designed to achieve maximum effectiveness. The health needs assessment process can help to build relationships among these stakeholders.
  • Ensure adequate staffing: Adopters should hire high-quality, full-time staff who can focus solely on program initiatives. New hires should have a diversity of experience and be able to offer creative ideas relevant to starting up a new organization.

Sustaining This Innovation

  • Maintain marketing and outreach activities: Many nonprofit organizations do not emphasize marketing, communications, and outreach, but these activities are critically important to sustaining the program. To that end, adopters should ensure that organizational leaders attend conferences and community events; commit funds for marketing and outreach activities such as Web site development and advertising; and solicit press coverage to highlight program accomplishments. This effort will help spread the organization’s message, solicit interest from funders and other potential partners, and generate community awareness and enthusiasm.
  • Integrate public and private health: Both public and private health organizations should remain involved to sustain the program's success, especially in communities interested in developing ACOs.

More Information

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Contact the Innovator

Trenton Health Team
218 North Broad Street
Trenton, NJ 08608

Ruth Perry, MD

Executive Director
(609) 989-3262 ext. 108
E-mail: rperry@trentonhealthteam.org

Gregory Paulson
Deputy Director of Programs and Operations
(609) 989-3262 ext. 188
E-mail: gpaulson@trentonhealthteam.org

Martha Cook Davidson
Director of Development
(609) 989-3262 ext. 172
E-mail: mdavidson@trentonhealthteam.org

Innovator Disclosures

Dr. Perry, Mr. Paulson, and Ms. Davidson reported having no financial interests or business/professional affiliations relevant to the work described in the profile other than the funders listed in the Funding Sources section.

References/Related Articles

Trenton Health Team. Transforming healthcare for the community with the community [Web site]. Available at: http://www.trentonhealthteam.org

Perry, RE. Building the infrastructure for a safety-net accountable care organization. American Journal of Accountable Care. Dec 2013 [in press].

Perry RE, Stephenson C. Improving population health through collaboration and innovation. Popul Health Manag. 2013;16(Suppl 1):S34-7. [PubMed]

Remstein R, Perry RE. The Trenton Health Team. Readmission News. 2013;2(9):1-3.

Footnotes

1 Hossain WA, Ehtesham MW, Salzman GA, et al. Healthcare access and disparities in chronic medical conditions in urban populations. South Med J. 2013;106(4):246-54. [PubMed]
2 Geronimus AT, Bound J, Colen CG. Excess black mortality in the United States and in selected black and white high-poverty areas, 1980-2000. Am J Public Health. 2011;101(4):720-9. [PubMed]
3 Fiscella K, Williams DR. Health disparities based on socioeconomic inequities: implications for urban health care. Acad Med. 2004;79(12):1139-47. [PubMed]
4 Katz Consulting Group, Inc. Making Trenton’s healthcare plans a reality. 2006.
5 Brock J, Mitchell J, Irby K, et al. Association between quality improvement for care transitions in communities and rehospitalizations among Medicare beneficiaries. JAMA. 2013;309(4):381-91. [PubMed]
6 Lippa J, Radley D, Schoen C. Improving care and health for low-income populations. Healthc Exec. 2013;28(6):70-3. Available at: http://www.ihi.org/knowledge/Pages/Publications/ImprovingCareandHealthforLow-IncomePopulations.aspx
7 Murray M, Berwick DM. Advanced access: reducing waiting and delays in primary care. JAMA. 2003;289(8):1035-40. [PubMed]
8 Babor TF, McRee BG, Kassebaum PA. Screening, Brief Intervention, and Referral to Treatment (SBIRT): toward a public health approach to the management of substance abuse. Subst Abus. 2007;28(3):7-30. [PubMed]
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Original publication: February 12, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: February 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.