Trenton Health Team (THT), a community health improvement collaborative serving Trenton, N.J., is pulling together information about clients’ clinical and social conditions to coordinate individualized care.
THT, which runs the Trenton health information exchange (HIE), has begun working with Chicago-based NowPow, a social services technology platform, to better connect Trenton residents to clinical and social services to improve their health and well-being. Providers at social service and healthcare organizations in Trenton will be able to conduct screenings to generate a customized list of social services tailored to a patient’s specific needs and geography. More than 25 Trenton-based organizations have already signed up to use the NowPow platform.
In a presentation last year, Stacy Lindau, M.D., chief innovation officer of NowPow, described the concept of clinicians e-prescribing community in much the same way they e-prescribe drugs now. For instance, NextLevel Health Partners Inc., a Medicaid managed care company, recently partnered with NowPow to better manage and address the social determinants that impact the health and wellness of residents across Cook County. NextLevel Health coordinators will use NowPow e-prescription methods as a way to deliver personalized community resources based on factors such as patient conditions, address, age, gender and preferred language.
In addition to providing information to patients about these services via text message, email, or print, providers using the NowPow platform can send a tracked referral directly to a community organization such as a food pantry or a homeless shelter, allowing the healthcare and social service provider to coordinate individualized care for that person and ensure the referred services were actually received.
Trenton Health Team’s implementation of the NowPow platform includes integration with its own HIE. The integration of these two technology platforms will, for the first time in Trenton, provide clinicians across the community with the ability to view a patient’s health and social conditions in a single location.
“Never before have our healthcare providers had access to a patient’s clinical record and social conditions in the same place,” said Gregory Paulson, THT’s executive director, in a prepared statement. “More and more, we are seeing that social determinants are driving health and well-being in our communities, and, by providing healthcare providers access to this information, we empower them to make the best possible decisions for their patients.”
The Trenton Health Team collaborative is a partnership among St. Francis Medical Center, Capital Health, Henry J. Austin Health Center, and the Department of Health and Human Services of the City of Trenton. Its mission is to transform healthcare for the city by forming a committed partnership with the community to expand access to high-quality, coordinated, cost-effective healthcare.
The Trenton Health Team was formed in response to the healthcare crisis in Trenton, with the intent to reform healthcare by establishing a holistic model. THT is working to make this holistic model a reality through five strategic initiatives:
• Expansion of access to primary care
• Community-wide clinical care coordination
• Engagement of residents
• Operation of the Trenton HIE
• Serving as a Medicaid Accountable Care Organization.
