Community networks save lives

  | November 8, 2017

Ready or not, hospitals are recognizing that medical care cannot stop at their doors. In one American city, a pioneering model of community-based coordinated care offers a roadmap forward.

Once a thriving manufacturing center, Trenton, New Jersey has been battered by poverty, violence, and intractable health disparities since the 1970s. But its story may change again, thanks to a remarkable collaboration between two hospitals, a federally qualified health center, the city's department of public health, and more than 60 food banks, churches, schools and other community-based organizations.

It's a model of multi-sector collaboration that works, says Glen P. Mays, Ph.D., professor in health services and systems research at the College of Public Health of the University of Kentucky.

Mays is the principal investigator in an analysis of 16 years of data from 360 communities that identifies five essential qualities of communities succeeding in caring for populations:

Mays' research found that preventable deaths due to cardiovascular disease, diabetes, and influenza declined significantly within a single year in those communities where population health activities are coordinated among clinical organizations, civic entities, and non-clinical advocacy and service groups. 

The more organizations involved — and the more varied — the better. Mays calls the effect "comprehensive system capital."

“It's about the strength of the network," he says. “Communities able to build strong networks for supporting population health are not only helping to improve health status for the population at large, but they're also making pretty remarkable strides in reducing disparities in health status within the communities."

In the case of Trenton, the path wasn't always easy. Fierce competitors had to become collaborators, and clinical organizations needed to learn to work with advocacy and service groups out in the community. But nine years in, they're still going strong.

The Trenton roadmap

Trenton's project began in 2006 when one of two acute care hospitals in the city announced its impending closure. The mayor launched a process to assess and mitigate the impact of one less hospital in a community with 52 percent higher utilization than the national average, inadequate access to primary care, and little coordination of care across the community.

An executive working group was formed of representatives from the two hospitals, Capital Health and St. Francis Medical Center (a member of Trinity Health), plus the local federally qualified health center Henry J. Austin Health Center and the city's department of health.

The healthcare leaders came to the table as competitors, but the first topic on the agenda quickly put them on the same page.

"We looked together at each hospital's list of high utilizers," says Eric Schwartz, M.D., executive director of Capital Health's Institute for Urban Care, "and said, 'Okay, John Smith has been to us 40 times. Do you guys know John Smith?' 'Yeah, we've seen him 30 times, so his number is actually 70.' And then, 'All right, what do we agree that we're going to do for John Smith next time he comes into our facilities?'"


Eric Schwartz, M.D., of the Capital Health Institute for Urban Care, helped found the Trenton Health Team

The collaboration kindled in the working group evolved to become, in 2010, the Trenton Health Team (THT). Now a 501(c)(3) nonprofit with a staff of 17 and a budget of $2.6 million, THT manifests the first essential characteristic identified by Mays' research: a neutral, convening backbone.

1. The backbone

Four competitors working together is unusual, but their ceding that work to a neutral, independent third party is even more so. The reality, says Gregory Paulson, Trenton Health Team's executive director, is that "getting competitive organizations to align around strategy is specific work. It requires an environment where they can learn to partner with a relatively equivalent stance."


Trenton Health Team's Gregory Paulson rallies diverse organizations around a shared vision to improve the health of the city.

And, says Kemi Alli, M.D., CEO of Henry J. Austin Health Center, the individual personalities and committed leadership at the table made it work. "We had buy-in from CEOs who trusted each other — and really do share a vision of Trenton as the healthiest city in New Jersey."

Then clinical founders of THT reached out to the community to form an advisory board of more than 60 agencies from many sectors: housing, food banks, rehab and behavioral health, education, first responders, and faith-based organizations throughout the city.


THT's community advisory board includes representatives from housing, food banks, behavioral health, education, and faith-based organizations.

"That's very much in line with our research looking across the country," says Mays. "The convening entity typically brings in large and diverse organizations into the network and then facilitates agreements about who's going to do what in the enterprise. That's really what it takes. And our data show that's still a pretty rare phenomenon."

2. Shared data

Trust also enables the next crucial step: Asking all of the organizations to turn over their clinical data to build a health information exchange. And that, says Paulson, requires, "setting up the right governance structure with enough transparency so that everyone could trust the process and share their data in one place."

Shared commitment drove the partners to build a health information exchange (HIE), still new territory at the time. "Our CIO was one of the first people around the table," recalls Schwartz. "Before people were really talking about HIEs, [we were saying] 'Wow, think about how powerful this would be.'"

Now a robust data repository, Trenton's HIE integrates with inpatient and ambulatory electronic health records and claims systems from all the major providers in the city, surrounding communities, and most of the labs in the area.

"Now, when we use that system to produce a measure on the population, that trust [between partners] is translated into a trust of what the data say," says Paulson. "It has resulted in a different way of making decisions."

Capital Health's care management team, in particular, relies on the visibility provided by data. "I was actually just sitting in a meeting in which we were able to collect data, have the care manager risk-stratify our patients, and use our care managers as links to the community," says Schwartz.

Aggregated data means "you're able to really target resources to needs identified in that community," says Mays, "and respond when those needs change over time."

3. Dense networks of diverse partners

Partnering with non-traditional, non-clinical organizations can be a high hurdle for traditional health systems. But in Trenton — and in Mays' data — making as many of those links as possible is foundational to success in population health.


Dr. Kemi Alli, CEO of Henry J. Austin Health Center, and a founder of Trenton Health Team.

"So much of the need of our patients falls outside of our realm," says Alli. "Our patients need housing. Our children need safe zones where there is no smoking. Our families need healthy places to buy their food. We have got to reach across the aisle to those non-healthcare orgs because we're not going to do it alone."

Even patients are being activated as contributors to, rather than simply recipients of, Trenton's healthcare collaborative. In a new initiative funded by Merck, for example, THT will train patients who manage their diabetes well to become mentors for neighbors still struggling with the disease.

The trick to helping clinical and non-clinical entities work together, says Paulson, is to start small. "Find low-risk areas of focus where partnerships can yield early successes, so that people see value in coming together."

Often, THT will learn a new best practice from a non-clinical partner. "Then our goal is to spread it so that this kind of care delivery can be community-wide," says Paulson. "It's a matter of recognizing strengths — and taking advantage of all the wonderful works that are going on in communities that health systems sometimes might not notice, actually."

Most important, says Mays, with diversity comes resilience. "It's an insurance policy against complexity and uncertainty. We see this when emergencies happen, like the hurricanes that have hit Florida and in Texas. As a hospital or clinic, you're likely to be a much more resilient organization if embedded in a network that you can draw on when unanticipated things happen."

4. Coordinated implementation

Collaborating on specific interventions requires honest, sometimes difficult conversations. A recent grant opportunity targeting opioid-overdose patients had Eric Schwartz of Capital Health wondering if his hospital and its emergency department were the best applicant, or if another entity in the city should take the lead.

So THT convened its community advisory board. While only one grant would be given in the county, it turned out that five organizations in the city were planning to apply for it. A week later, three decided to collaborate on a single proposal to put recovery coaches in the EDs who would meet patients at the bedside and get them into treatment. Another dropped out, and one submitted its own proposal.

"There's power in that," says Schwartz, "and a nice example of what collaborative work can really do."

5. Ongoing evaluation

The final essential ingredient in improving community health, according to Mays' research, is continuous evaluation and quality improvement. While certain metrics demonstrate improved trends in Trenton — ED use has been reduced by more than 45 percent across the city — "we have more work to do," admits Alli.

"Although we started in 2006, we didn't become a nonprofit until 2012, and didn't get our first grant until 2013. So, Trenton is still a toddler in terms of improving the health of a city," says Alli. "You're talking at least a decade to measure overall impact."

"Some of these cities have been so starved for resources for so long," she says. "If you do this long enough, and you really do put in manpower and resources, and are consistent and committed, you can't help but move the needle."

And letting time do its work, according to a new study that Mays will soon publish, is also essential. "The longer a community is able to sustain a comprehensive network over time, the larger the effects that we see," he says. "That's where trust really comes into play as having a big impact on the durability of these networks over time."

"I don't want to make it sound like it's easy," says Schwartz. "But health systems are incredibly important pieces of communities ... and have a wonderful opportunity to align resources and say, 'Hey, let's work together to overcome these issues.'"

Gale Pryor is associate editor of athenaInsight. Photography by Darlene DeVita for athenahealth. Portrait of Dr. Alli provided from Henry J. Austin Health Center.

Community networks save lives