Regional Health Hubs: A way forward in care coordination for New Jersey

Kathleen Noonan and Jon Tew

Strengthening ecosystems of care

New Jersey is suffering from the healthcare paradox. Despite high spending, health outcomes remain stubbornly poor, especially for vulnerable communities in urban centers. New Jersey spends more than $5 billion in state-only funds on the Medicaid population, which accounts for nearly one-sixth of state spending. As a result, our state government is under increasing fiscal pressure.

The healthcare delivery system cannot solve these problems on its own. A more regional approach to care is needed – one that involves coordinated, person-centered healthcare with robust connections to social services and community resources. An innovative infrastructure to do just that is underway in four communities across New Jersey: Trenton, Camden, Newark, and Paterson. Efforts begun in 2011 under New Jersey’s Medicaid Accountable Care Organization (ACO) Demonstration Project have evolved into four regional collaboratives that integrate, coordinate, and align all the disconnected programs aimed at making communities healthier.

State support for such local, community-based innovation has been critical. The initiation of the ACO Demonstration Project showed that its state-level champions are interested in innovative ways to improve care and reduce costs. The project was a clear success in that regard, generating important lessons and, most notably, showing a need for a neutral convener backed by cross-sector data to align the extraordinary energy in a community for the benefit of its residents. With the three-year Demonstration Project wrapping up its first one-year extension, it is now time to incorporate its successes more permanently into the health infrastructure of New Jersey.

Regional Health Hubs represent this next step. Envisioned as non-profit organizations dedicated to improving healthcare delivery and health outcomes, Hubs work in close concert with consumers and stakeholders in the region. The focus is on residents who receive healthcare coverage through Medicaid — those who often lack access to the resources needed to be, and stay, healthy. In his proposed FY 2020 budget, Governor Murphy allocated $1.5 million to maintain the current Medicaid ACO structure. The Camden Coalition, along with the other three regional collaboratives — Healthy Greater NewarkHealth Coalition of Passaic County, and Trenton Health Team — are now urging the state to build upon the lessons of the Medicaid ACO project and certify us as the first Regional Health Hubs in New Jersey.

Because New Jersey must respond to the ever-changing needs of its population, the state will be well-served in establishing the Hubs as a reliable mechanism that responds proactively to community and state needs. While each proposed Regional Health Hub will approach this task by leveraging the unique strengths of its partners and targeting the specific challenges of its region, each Hub will have five core functions:

  1. Operate or utilize a regional Health Information Exchange (HIE). A key advantage of each Hub is its robust data infrastructure. We gather and employ detailed health data leveraged through regional Health Information Exchanges (HIE). The reporting functions of the HIE are being continuously enhanced to include analytics at both the macro (population) and micro (individual, disease category, age group, or other subset) levels.
  2. Convene multi-sector partners around the region and facilitate priority initiatives. Each Hub already provides a community-based structure for convening stakeholders, and planning and executing population health interventions. We maintain a regional view of our communities, while supporting the health of each individual in that community. Working as partners, we have formed a network focused on improving wellbeing throughout the state.
  3. Facilitate care coordination for high need populations. Because each organization has close ties to clinical partners and a data infrastructure that allows for sharing across providers, each Hub is well positioned to effectively coordinate care for the Medicaid beneficiaries they serve. Not only do the Hub HIEs share clinical data, but they also enable us to directly address social determinants of health, as well. Our systems enable doctors to make direct referrals to food pantries, legal services, and other social services. They can also  alert health ministries at local churches when a congregant is admitted to the hospital.
  4. Operate as a clinical redesign specialist for providers, payers, and the state. Regional Health Hubs, with their community partners, prototype and pilot policies, tools, and interventions to improve health and wellbeing in vulnerable populations. The state, payers, and providers need organizations to innovate on their behalf and operate small population interventions in partnership with those stakeholders, in order to scale what works statewide. Innovation is key to the mission of Healthy NJ 2020, the Medicaid 1115 Waiver, and the Department of Health’s DSRIP (Delivery System Reform Incentive Payment) successor proposal. While the state, payers, and healthcare institutions all focus on innovation in their respective areas, there is no structure in place for the state to support sustainable and innovative clinical redesign across sectors. Regional Health Hubs can ensure that the innovation is locally focused, and that the partnerships described above enable quick improvements to care delivery.
  5. Serve as a local expert and conduit for state priorities. Regional Health Hubs will advise the state on regional needs, including physical and behavioral health, social determinants, and health equity in their communities. Not all areas of the state experience the same challenges in the same way, and Hubs can provide valuable knowledge of those differences and the way they affect state programs.

Once certified, we would work closely with the state to further refine these core functions and priorities. In its current iteration, we’ve seen results with this model across all four regional partnerships. Over the past year alone, we have worked with our partners to address inequities in maternal health outcomes, access to cancer screening and treatment, challenges in access to healthy food, connections between healthcare and the faith community, youth tobacco use prevention, school attendance, improvements to the built environment, and more.

In recognizing the four Regional Health Hubs, New Jersey will continue this important work and ensure that limited state resources are spent effectively and efficiently. Our Regional Health Hub model allows the state to strengthen and expand upon what we believe is a national model for state and local partnership to improve health outcomes.