The Trenton Times published the following op-ed on February 8, 2013. To read the full piece, click here.

Opinion: Trenton Health Team takes multi-pronged approach to improving city’s services

By Ruth Perry, Executive Director, Trenton Health Team

Trenton residents deserve better. Trenton’s underprivileged, one-quarter of whom have no health-care coverage, suffer from higher-than-average rates of diabetes, hypertension and obesity. Residents have little access to primary care, and, until recently, it could take weeks to get a clinic appointment. Instead, patients often visit emergency rooms for problems that are not emergencies. Using the ER this way is more expensive than using primary care services, and without follow-up care, the patient will probably end up in the ER again soon.

Combine the city’s poor health and poor access to health care with its other circumstances — a violent crime rate 4.5 times higher than New Jersey’s as a whole, 36.3 percent of the residents living below 200 percent of the federal poverty level and a child poverty rate of 32.6 percent — and we find a city where poverty combines with a broken system to create significant barriers to health and overwhelming health-care costs. The city’s most destitute also frequently face homelessness, substance abuse and mental health issues.

A glimpse into the emergency room reveals that many complaints are medical manifestations of social problems, unresolved life challenges such as poor nutrition and homelessness that negatively affect health. Health institutions are sometimes forced to treat patients when they know little about their situations, which can drive up costs significantly. For example, when the same patient visits multiple emergency rooms, there is no means for the institutions to share information. With no knowledge of treatment the patient may have received elsewhere, providers may end up duplicating efforts, which further drives up costs.

The system has failed Trenton’s most vulnerable. And our health-care providers, despite our best individual efforts, have not been successful in providing effective care for them — until recently.

When the 2010 Affordable Care Act health-care reforms were enacted, Trenton’s major health-care organizations had already been working together for four years to improve health-care delivery, transitioning from the traditional competitive approach to one of collaboration. The Trenton Health Team (THT) is a public/private partnership comprised of Trenton’s two hospitals, St. Francis Medical Center and Capital Health; the Henry J. Austin Health Center, the city’s only federally qualified health clinic; and the city’s Department of Health and Human Services. Additionally, most of the city’s community organizations have signed on as members of THT’s Community Advisory Board. As different health-care services work together to serve each patient, Trenton becomes a healthier place to live.

The Trenton Health Team is taking a multipronged approach to improving health services. It is developing a “medical home model” of health care that integrates health-care services, offering a patient-centered approach that eliminates duplication of services and excess costs. From the patient’s perspective, this means seeing the same physician or team of physicians for each primary care visit. THT has been able to match most patients with a designated caregiver who gets to know them and helps coordinate their care. THT is also creating a single electronic system for its partner organizations to share information in real time, allowing further coordination of care.

THT health-care providers have developed personalized treatment plans for Trenton’s highest users of emergency rooms, patients we identified by analyzing hospital data. Early data already show a 61 percent reduction of ER use at one of our partner organizations and a 30 percent reduction at another.

Medical practices can change how they work and improve each patient’s access to care. The Trenton Health Team used business principles to reduce clinic wait times. Our partners are all using this approach, with growing success. One of them reduced wait time from 37 days down to just two.

Community input is shaping THT’s Community Health Improvement Plan. Residents of Trenton are participating in our Community Health Needs Assessment to identify their most significant health challenges and barriers to care. THT is reaching out to hear the voice of the community through the forums and one-on-one interviews. We will gather more information this year and use it to make more positive changes.

THT’s efforts are an example of changes to health care that are required by new federal and state laws. Federal law created accountable care organizations (ACOs), where medical institutions partner to improve care, just as THT has done in Trenton. Federal law allows ACOs to form to serve elderly populations enrolled in Medicare. New Jersey law has expanded the reach of ACOs to include impoverished populations enrolled in Medicaid, which has offered the opportunity for THT to focus on Trenton’s vulnerable population. As a Medicaid ACO, we hope other cities across the nation can follow this example and give vulnerable populations a new chance to lead healthy lives.

Trenton residents deserve better health care. Through the efforts of all of us on the Trenton Health Team and our partners, they are beginning to receive it. With their active engagement, we fully intend to reach our goal of making Trenton the healthiest city in the state.

Ruth Perry, M.D., is executive director of the nonprofit Trenton Health Team (trentonhealthteam.org).