Published Online: December 12, 2013
Ruth E. Perry, MD
The Affordable Care Act (ACA) has stimulated a tremendous amount of discussion, debate, delight, and discord across our nation. Will it improve health outcomes, and willit lower costs? Will Medicaid expansion provide improved access to care for our most vulnerable patients across urban and rural America? Will there be enough providers to provide care to an expanded base? Will I be able to adequately care for my highly complex patients when I can only spend 15 to 20 minutes with them? Will I be able to break even and maintain my practice?
These, and a host of other questions, are critically important, and the answers are not easy or clear. It is human nature to view change through the lens of danger. However, I believe that we have to look through the lens of opportunity as well and ask ourselves the following questions: “What should high-quality care look like, and how should our healthcare system function to best meet the needs of patients?” If we take time to envision the outcomes we desire, we can begin to reverse-engineer the system so that it delivers these very outcomes.
Some important elements of a new healthcare system include: a collaboration between all healthcare providers and payers in a community; expansion of access to primary care; integration of mental health and primary care services; coordination, navigation, and management of care; implementation of evidencebased treatment plans; utilization of data to manage health at the individual and population level; participation of the community,and innovation support, from the government at all levels, for new models of care delivery and payment.
The state of New Jersey is working to redesign its healthcare system to include many of these new elements. New Jersey is the first state in the nation to pass legislation providing for safety-net accountable care organizations (ACOs). Coalitions in Camden, Trenton, Newark, and Atlantic City are poised to participate in this safety-net ACO demonstration project.
In Trenton, the work had begun long before the ACO legislation was passed in 2011. Trenton’s healthcare providers realized the problems facing the community were greater than what 1 individual or organization could solve alone and decided to act on that realization in 2005. The 4 major healthcare providers— Capital Health, St. Francis Medical Center, Henry J. Austin Health Center, and the City of Trenton Department of Health and Human Services—have become collaborators and formed a community-based health improvement organization called the Trenton Health Team (THT).
To date, THT has made progress in improving healthcare for city residents, while at the same time beginning to contain, and in some cases even reduce, costs. It has expanded access to care by implementing advanced access scheduling, reduced emergency department (ED) and inpatient recidivism through a communitywide care coordination team, engaged the community by forming a community advisory board and performing a unified community health needs assessment/health improvement plan, and integrated behavioral health and trauma-informed care into primary care.
THT achieved an early success with advanced access scheduling (AAS). AAS enables outpatient clinics to offer patients appointments on the same day or the next day and has been shown to reduce use of EDs. THT involved all 7 of its outpatient clinics in this initiative, and within the first year, there were remark able accomplishments in the areas of patient-provider continuity, quality of care, and efficiency. For example, patients at the St. Francis Medical Center were unable to see the same provider or provider team each time they visited the clinic when this program began. Within a year, they achieved 95% patient-provider continuity. The Henry J. Austin Health Center improved its third-next available (TNA) appointment rate from 37 days at the beginning of the initiative to 2 days following the implementation of the advanced access scheduling program.
The hospital-funded high utilizer teams, coordinated through the communitywide Clinical Care Coordination Team (C4T), have had early success managing patients with high rates of ED use and in-patient recidivism. Between the 2 hospitals within the city of Trenton there was a 45% reduction in ED visits, a 56% reduction in inpatient stays, and a 48% reduction in inpatient charges for the 100 highest volume utilizers served in this program. Ten high-utilizer homeless patients with significant medical problems were connected with housing professionals and received housing vouchers. Upon receiving housing there was a 73% reduction in ED visits, a 100% reduction in inpatient stays, and a 100% reduction in inpatient charges. The significant reduction in charges for these high utilizers will be foundational to bending the cost curve as THT moves to be an accountable care organization.
To begin addressing the city’s health issues, THT utilized the IRS’s community health needs assessment (CHNA) and community health improvement plan (CHIP) obligation as an opportunity to complete a comprehensive health needs assessment for our geography in an innovative way. First, we performed a unified community health assessment in place of separate assessments as was done in the past. Second, we shifted our approach from one that viewed this as a “requirement” to one that engaged the community and permitted the voice of our community to illuminate the successes, as well as the barriers and challenges, that Trenton residents face in maintaining their health.
The CHNA methodology involved 3 major components. The first was to form a community advisory board (CAB). This organization was chartered in late 2011 and reports directly to the THT board of directors. This board consists of 40 unique community organizations which include municipal, county, and state government, behavioral health providers, social service agencies, academia, homeless service providers, and the faith community.Members of the CAB that possessed community data shared their information with the THT. In turn, THT committed to sharing our compiled data with the CAB. Second, THT performed a retrospective data analysis utilizing data from all of the hospitals and outpatient clinics. These data have been analyzed in a very robust manner and key healthcare trends have been geo-mapped to the zip code level. The third component involved THT contracting People Improving Communities through Organizing (PICO), to help obtain the voice of the community through one-on-one interviews and community forums across our geography. Many of the one-on-one interviews were videotaped, creating a permanent first-person narrative record of the health challenges facing our community. Twenty-five community forums were led by members of the THT executive team, which enabled us to hear the unfiltered voices of our residents. This element is unique to our methodology and demonstrated how quantitative and qualitative data can be mutually reinforcing and useful in refining our understanding of barriers to good health in our community.
Six priorities have emerged in the CHNA. Poverty, the overarching priority, influences the others, which include crime, chronic disease, substance abuse/mental health, obesity, health literacy, and health disparities. We are in the final stages of completing our CHIP and will hold a public meeting to discuss our findings and share the plan with community members and stakeholders.
A great deal of this early transformative work in Trenton and across the state preceded the ACA. Now that the ACA has passed, along with Medicaid expansion in New Jersey, we can reflect on our early successes to scale up our work to impact more individuals in our community, and serve as a model for other communities across the state and the nation.
The Chinese character for the word risk includes the characters for danger and opportunity. With the tools of courage, reason, data, and collaboration, the Trenton Health Team chose to focus on the opportunity to lay the foundation for an ACO to transform healthcare for the people of Trenton into a high-quality system, which they deserve.