Payer Leading Social Determinants of Health Program in New Jersey

The pilot program achieved a 25% reduction in total cost of care. “Those members were utilizing emergency rooms, they were being admitted to hospitals, they were being readmitted, and they were running up significant costs. They were not well-connected to the healthcare system—nobody was coordinating care for them,” he says.

In April 2020, Horizon launched an expanded version of the pilot program called Horizon Neighbors in Health. The program includes 10 partners. Eight of the partners are healthcare provider organizations, including four of New Jersey’s largest health systems—Atlantic Health System, Hackensack Meridian Health, RWJBarnabas Health, and St. Joseph’s Health. The two other partners are Penn Medicine for community health worker training and NowPow, which features an online platform that can connect people with community-based resources.

How Horizon Neighbors in Health works

The Horizon Neighbors in Health program has five essential components, says Valerie Harr, director of community health for Horizon.

1. Community health workers: About 40 community health workers have been hired to work in the Horizon Neighbors in Health program. Horizon’s healthcare provider organization partners recruit and hire the community health workers and Horizon pays for half of the salary cost.

“Community health workers are recruited from the local community. If we are working with St. Joseph’s, the community health workers live in Passaic and Patterson. Resumes and degrees are not as important as being a trusted member of the community. Candidates need to understand the needs of the community and have the ability to connect with individuals,” Harr says.

The community health workers are advocates for the members who are served by the Horizon Neighbors in Health program, she says. “People are often reluctant to ask for help. But if someone approaches them who is a neighbor, who speaks their language, and who looks like them, then they may open up. The community health worker is responsible to help identify the goals of the member and to make community connections.”

The original plan for the community health workers was for them to have face-to-face interactions with members, but the coronavirus pandemic necessitated shifting to telephonic contact with members.

2. Screening: Community health workers screen targeted Horizon members for nearly two dozen SDOH. “These community health workers have conversations with our members—they build a rapport with members while going through the screening tool,” Harr says.

3. Geographic approach: Horizon has used U.S. Census data to target members in communities with high SDOH needs, she says. “Horizon’s footprint is nearly statewide, but Horizon Neighbors in Health is not yet in every county. We are in 15 counties and more than 120 zip codes. That is intentional. We are targeting the communities with the members who have the most need.”

4. Personal health assistants: Horizon has hired and fully funded four personal health assistants to support the community health workers, Harr says. “They each have a provider partner that they are responsible for, and they have daily huddles with their respective partners to troubleshoot issues that community health workers are encountering. The personal health assistants can connect members with resources such as care management or our behavioral health team. They also troubleshoot issues around pharmacy.”

5. Data analytics: “Working with McKinsey & Company consultants, our analytics team has built multiple predictive algorithms using claims data, consumer purchasing data, Census data, and other SDOH data to zero in on the members who can benefit most from having a community health worker engage with them,” she says.

Emphasis on community resources

The primary goal of the Horizon Neighbors in Health program is to connect members with SDOH needs to community-based resources, Harr says.

“NowPow is known for having connections to community resources. In New Jersey, they have more than 20,000 community organizations loaded into their platform. When a community health worker engages with a member and identifies needs through the screening process, NowPow identifies the potential community resources for that member. For example, if a member has food insecurity, NowPow can identify a food pantry in that person’s neighborhood,” she says.

In some cases, Horizon pays to meet a member’s SDOH needs, Harr says. “We do have funding set aside as part of the Horizon Neighbors in Health program to be able to pay for short-term assistance that may not be available through a community resource. For example, we had a member living on the second floor of a home with a broken chair lift. She had been crawling up and down her stairs. So, we paid for the installation of a new chair lift.”

Metrics and mission

Horizon expects to have data that measures the impact of Horizon Neighbors in Health next month. The data will include several metrics, Harr says.

• Process metrics such as how many members are reached, needs that are identified, and referrals
• Excess spend, which is defined as avoidable emergency room visits and inpatient admissions
• Total cost of care
• Qualitative metrics related to chronic conditions
• Pharmacy utilization

“Ultimately, for us to see whether we are having an ROI, we must engage a large enough pool of members and reduce excess spend. That will get us the ROI,” she says.

A recently published progress report on the Horizon Neighbors in Health program includes three key data points through December 2020.

• More than 2,500 Horizon members were enrolled in the program
• The Top 3 needs identified were financial stability, access to basic healthcare, and food insecurity
• The Top 3 referrals were food pantries, utility payment assistance, and rent and mortgage assistance

Horizon is dedicated to addressing SDOH, Karp says.

“We are committed to solving disparities in healthcare and underserved communities in New Jersey. We cover not only commercial members but also more than a million Medicaid members and a significant share of the individual insured market. We want to ensure that our members have appropriate access to care, so they can achieve their best health. Many members face a lot of barriers to care because of where they live such as lack of transportation and housing,” he says.