This section of The Nicholson Foundation website provides brief summaries of programs and projects funded by the Foundation between 2002 and 2009. These program areas include:
- Helping At-Risk Youth Stay in School
- Reducing Homelessness in Newark and Essex County
- Reducing Recidivism for Ex-Offenders Returning to Essex County
- Improving Family Stability and Child Well-Being
This section also provides a description of early developmental work in the Foundation’s healthcare program area:
Beginning in 2002, The Nicholson Foundation joined with government agencies, service providers, and community organizations in Newark to develop strategies and programs to address the critical issues facing the City’s children and families. A major concern identified by Newark’s stakeholders was the adverse impact on family and community stability caused by the significant number of high school dropouts. In Newark, as in other large cities across the nation, almost half of the students who start high school fail to finish. Compared to students who do graduate, dropouts are more likely to be unemployed or have low earnings, receive public assistance, suffer health problems, spend time in prison, and/or have children who will also drop out of school. Their communities suffer economic losses due to lower productivity and lower tax revenues; have higher costs associated with healthcare, incarceration, welfare, and other social services; and experience greater neighborhood instability as a result of increased crime.
Recognizing that Newark has important strengths on which to build, community stakeholders in collaboration with the Foundation initiated a number of projects to help at-risk youth complete high school and prepare for post-secondary education or obtain employment. Working with government and community partners to develop these initiatives, the Foundation relied on research findings to identify best practices for engaging at-risk youth. The best practices included setting high expectations and fostering a positive environment, offering alternative educational programming with a variety of learning options, creating small learning communities, matching services and programs to each student’s unique needs, and partnering with community agencies to maximize access to necessary resources. Consistent with Nicholson’s belief in the importance of using research findings to shape program design, the Foundation funded evaluations of several of the alternative education programs it supported.
One of Nicholson’s supported programs was the Youth Education and Employment Success (YE2S) Center—a one-stop resource for Newark’s high school dropouts, those at risk of dropping out, and those returning from the juvenile justice system. The Center was a collaboration among various government agencies, educational institutions, community-based organizations, and The Nicholson Foundation. The YE2S Center’s programs and services exemplified and incorporated evidence-based principles by providing an individualized assessment, matching each youth to an appropriate alternative education program or employment, and providing specialized services to help the youth overcome barriers to his or her educational and vocational goals.
In addition to the YE2S Center, several innovative alternative school programs were implemented. The Newark Workforce Development Institute (NWDI) was established to reengage dropouts who could benefit from a strong employment focus. The Virtual High School allowed students who are unable to attend a traditional school program to complete their high school requirements through computer-based distance learning. Gateway to College, located at Essex County College, allowed dropouts to earn a high school diploma along with college credits. The Foundation also funded outreach, mentoring, and job-preparation programs for disconnected youth, as well as initiatives that connect pregnant and parenting teens with pre- and postnatal services, while helping them stay in school.
Because of the progress made in implementing innovative programs for disconnected youth, Newark received recognition for its accomplishments from the National League of Cities. It was selected for their prestigious Alternative High School Initiative, which introduced a community’s stakeholders to promising models and helped implement those they select. The Nicholson Foundation and its partners’ efforts to improve Newark’s high school graduation rate helped gained broad political support for this issue at all levels of government, and increased the likelihood that additional resources would become available to help Newark’s at-risk youth develop the skills to lead stable and productive lives.
Summary prepared: 2009
The Nicholson Foundation worked with government agencies, community organizations, and other stakeholders to develop strategies and interventions to address some of the most critical social issues affecting the residents of Newark and other Essex County municipalities. The Foundation’s efforts were primarily focused on enhancing family and community stability, helping at-risk youth, supporting ex-offenders to reintegrate successfully into their communities, and facilitating access to healthcare. While developing programs in these areas, the Foundation and its partners recognized that homelessness also is a significant risk factor, which could diminish the positive impacts of these programs if not adequately addressed.
Homelessness—living on the street or other public place or in a temporary shelter—is typically part of a long period of housing instability marked by frequent moves, overcrowding, and doubling up with relatives and friends. Without the stability of a home of their own, homeless parents are unable to create a safe and nurturing environment for their families. Especially for children, being homeless can have devastating effects on mental and physical well-being. Compared to children who are housed, children who experience the stress of homelessness show higher rates of health, emotional, and educational problems, including a greater likelihood of not completing high school. For many ex-offenders, not having a place to live upon their release from prison exacerbates their difficulty in accessing the services needed to successfully reintegrate into their communities. Finally, the homeless are more likely to use expensive, publicly funded, and often emergency-driven, treatment services for healthcare.
In 2009, a one-night Point In Time Count (PITC), conducted to determine the number of homeless, found more than 1,000 homeless adults and 650 children in Essex County, with almost 90 percent of them—900 adults and 500 children—in Newark alone. Based on the PITC, it is estimated that over the course of a year there are close to 4,000 homeless adults and children in Newark.
Recognizing the negative impact of homelessness on families and communities, The Nicholson Foundation supported the Essex County efforts of the Corporation for Supportive Housing (CSH). CSH is an experienced and well-regarded national organization with expertise in helping communities create permanent housing for the homeless. In Essex County, CHS collaborated with State, County, and municipal governments, as well as community partners, to develop and implement the Ten Year Plan to End Homelessness in Newark and Essex County (the Ten Year Plan). The Foundation also supported a Policy Advisor on Homelessness and Housing Development within the Newark Office of the Mayor. The policy advisor, working closely with CSH, coordinated the efforts of Newark agencies and local stakeholders to develop and implement the Ten Year Plan in Newark.
This plan, approved in 2010, set forth the goals, as well as the interventions and implementation strategies, to ensure that all individuals and families who are homeless, or at risk of homelessness, have access to stable and permanent housing with the resources needed to sustain it.
The primary goals of the Ten Year Plan included:
- Strengthening homeless prevention efforts,
- Expanding permanent low-cost housing, including supportive housing units for special needs groups,
- Improving access to housing resources and services through centralized intake locations,
- Enhancing coordination among providers through the development of a system-wide, real-time computerized resource listing, and
- Securing more effective public policies and adequate funding from government and philanthropic sources to support homeless initiatives.
The evidenced-based Housing First model provided the building blocks for the Ten Year Plan. Housing First required a shift to permanent housing away from a reliance on emergency shelter and transitional housing, which had been the standard practice in Essex County. Numerous studies have demonstrated that the Housing First approach leads to better outcomes for the homeless, including greater housing stability, improvements in physical and behavioral health, and increased income. This model recognizes that while some homeless individuals and families may require ongoing supportive services to remain housed, many simply need housing they can afford.
The Ten Year Plan also recommended the expansion of supportive housing, which is low-income permanent housing combined with services for individuals and families with special needs, such as those with serious mental illness and/or substance abuse disorders, ex-offenders, and youth transitioning from the foster care system. Studies demonstrate that it is no more expensive to provide supportive housing than continue with the shelter-based approach with the homeless cycling between shelters, streets, emergency rooms, jails, and mental health facilities. Moreover, supportive housing has been shown to reduce recidivism rates for ex-offenders returning to their communities after incarceration.
Summary prepared: 2010
Beginning in 2002, The Nicholson Foundation joined with government agencies and community organizations to develop strategies and interventions to address some of the most critical issues affecting Newark’s residents. The area’s high crime rate, with its adverse impact on public safety and community stability, was a critical issue affecting the quality of life in the City and in surrounding urban Essex County. In 2002, 46,000 Essex County residents—6 percent of the County’s population—were arrested. In Newark; one out of six adult males had a felony conviction. Between 1980 and 2002, the number of New Jersey residents entering prison annually—including Federal, State, and County facilities—had increased almost four-fold from 4,000 to 15,000, and approximately one-third came from Essex County. The increase in the prison population led to a corresponding increase in offenders returning to Essex County communities, where few social and economic supports were available. Because national data indicated that two-thirds of released offenders are rearrested within three years of their release—many within the first six months—collaborative efforts to address the destructive cycle of recidivism became a Foundation priority.
Although newly released offenders confront many challenges when they return home, including substance abuse and chronic unemployment, research has shown that if they receive comprehensive and integrated services early in their reentry, they have a much better chance of successfully transitioning from prison to the community. In developing reentry programming, The Nicholson Foundation and its government and community partners identified evidenced-based best practices, including pre-release reentry planning, education and job-training during incarceration, job placement post-release, expedited access to post-release benefits and services, and collaboration and support from parole agencies to implement reentry plans. In addition, as newly released prisoners have multiple service needs and difficulty navigating among service providers, case management is essential to facilitate access and coordination of services, both within specific service programs and across providers.
One of the evidence-based reentry initiatives supported by The Nicholson Foundation was Opportunity Reconnect, a one-stop reentry center for returning Essex County offenders that was designed to promote effective social and community reintegration. A number of government agencies and community organizations, located on-site, provided access to critical services, including welfare, Medicaid, housing, health, and family reunification as well as education, workforce preparation, and job placement. This co-location made it easier for newly released ex-offenders to access services and for agencies to coordinate those services.
Other criminal justice initiatives supported by The Nicholson Foundation included in-prison education and skills development, discharge planning, and targeted post-release activities. Nicholson funded evaluations of several of these initiatives, including Opportunity Reconnect.
The reentry programming efforts by the Foundation and its partner agencies helped spur recognition by policymakers at all levels of government of recidivism as a serious social and fiscal problem. In collaboration with the Foundation and its partners, the State of New Jersey replicated the successful Opportunity Reconnect service model in several other counties. Additionally, in recognition of the innovative reentry programs being implemented in Newark, the U.S. Department of Labor funded a Prisoner Reentry Demonstration Initiative in partnership with the City, the State of New Jersey, and with community organizations and private foundations including Nicholson.
Summary prepared: 2009
Beginning in 2002, The Nicholson Foundation joined with government agencies, service providers, and community organizations in Newark to develop strategies and programs to address the critical issues facing the City’s families. More than half of Newark’s families are poor or low-income. Many of the City’s children live in families headed by a single parent with limited education, and in neighborhoods with high concentrations of poverty and crime. When families live under these conditions, the capacity for consistent and involved parenting, necessary for a child’s healthy development, can be diminished. Other challenges prevalent in Newark’s disadvantaged families, such as domestic violence, substance abuse, health problems, and mental illness, also affect parents’ ability to adequately care for their children. Without stable and consistent parenting, children are less likely to become healthy and productive adults.
The Foundation and community stakeholders recognized that the cumulative impact of the economic and social challenges facing many of Newark’s families contributed to a pattern of intergenerational family dysfunction. Given the central role of the family and the importance of nurturing and consistent parenting for healthy child development, Nicholson’s partners developed programs to enhance family stability and child well-being. In implementing these programs, they incorporated evidence-based and promising best practices—in particular, community-based family support programs, the one-stop program model, and specialized one-stop centers.
Among the resulting Nicholson-supported initiatives were seven Family Success Centers (FSCs). These Centers, located in disadvantaged areas of Newark and surrounding urban communities in Essex and Union Counties, were neighborhood-based one-stop resources providing a wide range of coordinated services designed to promote family stability and child well-being. The Centers served all families residing in their neighborhoods and offered both on-site services and linkages to community resources. The services included eligibility screening and applications for government benefits, on-site parenting classes, parent-child activities, support groups, and anti-violence workshops, as well as referrals for health, mental health, social, educational, job readiness, and job placement services. The Foundation supported the development and implementation of a unified FSC data management system to improve service delivery, facilitate the coordination of services, and evaluate their effectiveness.
Additional initiatives that The Nicholson Foundation supported were specialized one-stop centers for families and family members with unique needs. These Centers served grandparents and other kinship caregivers, non-custodial fathers, and victims of domestic violence. The Essex County Grandfamily Support Center provided a wide range of services tailored to meet the needs of kinship caregivers, including financial, legal, housing, and other supportive services, as well as referrals to community providers for educational, health, and mental health services. Two Comprehensive Centers for Fathers, in Newark and Camden, served non-custodial fathers who seek to play a more positive role in their children’s lives. These Centers provided services to help the fathers become self-sufficient, comply with their child support responsibilities, reconnect with their children, and develop better parenting skills. The Essex County Family Justice Center, designed to be a one-stop multidisciplinary center for victims of family violence, provided and coordinated all needed emergency, medical, counseling, social, and legal services in one location.
The Foundation’s efforts to help vulnerable families encouraged the City of Newark and the State of New Jersey to demonstrate a commitment to initiatives designed to promote family stability and child well-being. The City was an essential partner in the development and operation of all the Newark-based FSCs and specialized family one-stop centers. Following the successful implementation of the Newark-based FSCs, the State began funding a statewide network of 37 additional Family Success Centers.
Summary prepared: 2010
Annual healthcare spending in the United States is approaching $2.2 trillion—one in every five dollars spent—yet millions of people are uninsured or underinsured, rates of preventable chronic diseases are high, access is a problem for many, and high-quality, well-coordinated care is not the norm. States across the nation are struggling with how to improve the quality of healthcare and reduce its cost.
In 2002, The Nicholson Foundation began working with families and communities in New Jersey’s urban areas to improve the lives of vulnerable populations and enhance the design, delivery, and effectiveness of human services. As this work progressed, it became increasingly clear that the social issues addressed by Foundation grants and technical assistance were intertwined with a variety of healthcare access, delivery, and outcomes issues. The Foundation realized that it could not maximize the success of existing program areas—at-risk youth, offender reentry, and fragile families—without also addressing access to healthcare and the organization and delivery of healthcare services.
Like other states, New Jersey’s healthcare system has evolved in response to demographic, social, political, and financial forces. New Jersey’s population is aging, with nearly all growth occurring in older age groups and among Hispanics, Asians, and multi-racial individuals, making it more racially and ethnically diverse. Although most of New Jersey’s employers offer health insurance, the State still has 1.3 million uninsured residents (15 percent of the non-elderly population). Data indicate that New Jersey’s healthcare system results in high cost and only average quality, with little association between costs and outcomes. According to the Commonwealth Fund,1 New Jersey ranks 30th among the 50 states in overall “health system performance.” It also falls in the middle on many indicators, such as access to care, prevention and treatment quality, and healthcare equity. It ranks a poor 48th, however, on cost and avoidable hospital use. Supporting this finding, the Dartmouth Atlas of Healthcare2 shows that New Jersey tops the nation in high-cost, intensive services for Medicare patients in the last two years of life.
Conditions in the State’s urban areas starkly highlight the realities of New Jersey’s healthcare system and the difficulties the State faces in achieving high-quality, cost-effective care for all. For example, Newark (New Jersey’s largest municipality, with a population of nearly 300,000) grapples with an array of intransigent social and economic problems. Compounding these problems are high rates of preventable and chronic diseases and their risk factors. Healthcare disparities and inefficiencies in the healthcare delivery system further exacerbate these problems. One-third of Newark’s population lacks any form of health insurance, and the City has an oversupply of specialists and hospitals, few primary care providers, and little coordination among healthcare services.
In response to these demographic and health imperatives, staff at The Nicholson Foundation began to look for opportunities to foster healthcare initiatives that could have a positive effect on the lives of New Jersey’s vulnerable populations. In doing so, the Foundation hoped to support sustainable systems change and enhance the impact of efforts in its other program areas. Staff were particularly interested in promising projects that could be even more successful or achieve goals faster with the Foundation’s support.
Ongoing national healthcare reform initiatives have been an excellent backdrop for these efforts because they address many of the same issues that engage the Foundation’s interests—improving access and quality, enhancing coordination and engaging stakeholders, improving use of information technology, and reducing costs. One of these reforms, the 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, requires that insurance benefits for behavioral health (mental health and/or addiction) be at least equal to coverage provided for physical health. Passage of this law provided a catalyst for the Foundation’s work on integrating behavioral health services into primary care and improving the quality of substance abuse treatment.
The passage of the 2010 Patient Protection and Affordable Care Act provided another critical impetus for the Foundation’s work. This law, the most significant systemic reform of the U.S. healthcare system since the establishment of Medicare and Medicaid in 1965, guarantees health insurance for all citizens and makes primary care the central feature of a transformed healthcare delivery system. It also realigns financial incentives of providers and hospitals and decreases reliance on specialists and emergency departments. Under this law, primary care providers will be asked to implement models of care that use electronic health records, encourage multidisciplinary healthcare teams to enhance care coordination, facilitate timely access to care, and provide health education. The Affordable Care Act provides funding opportunities for New Jersey and its urban communities to rethink the way healthcare is provided and try new approaches that can improve individual and population health while reducing costs.
Since 2009, The Nicholson Foundation has provided grants and technical assistance to support the development and implementation of innovative, sustainable healthcare programs. These programs, which are aimed at improving the physical and behavioral health of New Jersey’s vulnerable residents and reducing the cost of providing healthcare, are described below.
Key Themes for Programs to Improve Healthcare for Vulnerable Populations
Accelerating and Improving Healthcare Reform Efforts at State and Regional Levels
In 2001, Jeffrey Brenner, MD, was a primary care provider working in low-income neighborhoods in Camden. By analyzing information about the patients in his area, he realized that a small number of residents generated an outsized share of medical costs: one percent of the 100,000 people who used Camden’s medical facilities accounted for 30 percent of the costs. Furthermore, people with the highest medical costs—those who were hospitalized often, those who used the emergency department as their main source of care, and those who sought care only when medical conditions became urgent—often received the worst care.
Dr. Brenner hypothesized that intervening personally and intensively with high-cost users could improve health outcomes and lower Camden’s healthcare costs. He and other local physicians, hospital staff, social workers, and health services organizations began to meet regularly to share information and discuss common challenges they faced in providing care to high-cost users and other at-risk residents of Camden.
Eventually, they formed the Camden Coalition of Healthcare Providers to improve communication, collaboration, and coordination and thereby enhance the capacity, quality, and accessibility of healthcare. The Coalition now operates a program that uses care coordination teams to intervene intensively with high-cost users of emergency departments and other hospital services. Other Coalition programs focus on improving outcomes for people with diabetes and fostering collaboration across clinics, practices, and hospitals through shared patient-care data.
Since 2010, The Nicholson Foundation has supported the Camden Coalition’s work as one way to apply national healthcare reform principles to efforts at the State and local level. The Foundation also has given Dr. Brenner resources to provide training and technical assistance to replicate the Camden model in emerging healthcare coalitions in Newark and Trenton. With these resources, Dr. Brenner has helped the coalitions respond to new Nicholson funding opportunities that are intended to strengthen the coalitions in three key areas highlighted by the Affordable Care Act—coordinating care, collecting and analyzing data, and providing and enhancing primary care services (such as through open-access scheduling). In line with an important principle of the Act, these Nicholson opportunities link funding to outcomes by stipulating that about 30 percent of the full value of the grants depends on the coalition achieving specific outcome objectives, such as reducing emergency department use by 15 percent by targeting high users.
Strengthening the coalitions in this way better positions them to become Medicaid Accountable Care Organizations (ACOs) under a new three-year demonstration program overwhelmingly approved by the New Jersey Legislature in June 2011 and signed into law by Governor Christie on August 18, 2011. Initially, ACOs were a new Medicare feature proposed under the Affordable Care Act, but they are being adapted for Medicaid in this legislation. In the Medicaid ACO Demonstration Program, participating providers and institutions in a particular region formally collaborate with the State of New Jersey, through its Medicaid Division, and with Medicaid managed care companies to improve quality and reduce costs.
The Medicaid ACO Demonstration Program does not alter the way the State pays Medicaid claims. Instead, it creates incentives for participating providers to improve access to primary, behavioral, and dental services. Providers also must achieve specific quality standards and improve care coordination and information sharing. A key element of the legislation is to provide mechanisms and incentives for the healthcare providers that are members of each regional ACO to work together to better serve the most expensive Medicaid patients. The ACO can retain a portion of the savings that are realized through these improvements, a feature called gainsharing. The State of New Jersey will use the remaining savings to increase services needed for continuous quality improvement, such as funding for educational initiatives to increase the supply of primary care and behavioral health providers. To ensure broad provider engagement in the program, the legislation requires significant participation by the hospitals, primary care providers, behavioral health providers, dental and pharmacy services, and other health providers in each Medicaid ACO region.
The Foundation has worked with many New Jersey healthcare stakeholders, including hospitals, State officials, primary care providers, and community health centers, to educate their organizations about the Medicaid ACO legislation. For example, the Foundation supported a workshop in Trenton in January 2011 to explain the legislation and the principles behind it. The workshop also stimulated discussion about ways that organizations could be prepared to participate in a Medicaid ACO when the legislation passed. More than 300 healthcare stakeholders from across New Jersey attended the workshop. In addition, the Foundation funded about 25 people from the Camden, Trenton, and Newark Coalitions, the State of New Jersey, and other groups to participate in the Brookings-Dartmouth ACO Learning Network.
The Network provides in-depth training, technical assistance, and conferences on ACOs. Nicholson also has funded the New Jersey Health Care Quality Institute to convene quarterly meetings to familiarize participants with ACO issues. As part of this effort, the Institute also coordinates visits to organizations in other states that exemplify tightly integrated delivery networks. The events are valuable opportunities for individuals and groups from across New Jersey to share their healthcare reform experiences, build relationships, and understand how the State’s healthcare performance compares with that of other states.
Encouraging Consumer Participation in Healthcare Reform Efforts
Although healthcare reform largely focuses on providers and organizations, the actions of consumers are critical, too. Consumers must be able to negotiate an increasingly complex healthcare system. They need to know how to care for their own health and manage health conditions. Health literacy and self-efficacy are prerequisites, yet many people have difficulties with both. The Nicholson Foundation is engaged on several fronts to support New Jersey organizations that are helping consumers successfully negotiate the healthcare system and manage their health.
The Foundation is funding Camden Churches Organized for People (CCOP) to replicate and expand a successful community-organizing project called the New Jersey Healthcare Problem-Solving Initiative (HPI). The project creates local healthcare problem-solving partnerships in “hotspots”—neighborhoods with especially high-cost, low-quality healthcare. It uses a five-step model to engage residents so they can make better decisions about their healthcare. CCOP has expanded the HPI project in Camden and carries out similar work in Trenton through a subcontract with the New Jersey affiliate of People Improving Communities through Organizing (PICO), a national network of congregation-based community organizations.
The Foundation also is supporting efforts to expand the use of the Stanford Chronic Disease Self-Management Program in healthcare and community settings. This evidence-based program is designed to help people manage their health conditions, communicate effectively with health professionals, and maintain healthy eating and exercise patterns. Disease self-management programs can boost people’s self-confidence in their ability to manage their illness, improve their health, and increase their ability to interact with the healthcare system.
A third Foundation initiative focuses on another key aspect of consumer engagement in the healthcare system. Nearly nine out of 10 adults have trouble understanding and using health information. Without this understanding, people are more likely to skip needed tests and procedures, make mistakes when taking medications, and have trouble managing their conditions. The result is poorer health outcomes and higher costs. To address this issue, the Foundation funded a pilot health-literacy training program for staff of the Camden Coalition of Healthcare Providers. The New Jersey Health Literacy Coalition briefed staff on the literacy-related tasks and skills patients need to navigate Camden’s healthcare system and provided strategies to help staff communicate in clear, simple language.
Facilitating the Adoption of Health Information Technology
A critical component of healthcare reform is encouraging providers to adopt electronic health records and other health information technologies so they can make better use of the data generated by the healthcare system. These data help communities make informed decisions about where to focus their efforts to improve population health. Health information technologies also create opportunities to improve individual health and reduce costs because they help providers and patients jointly address health problems early and reduce unnecessary or duplicative care. The Nicholson Foundation is promoting the adoption of health information technology in several ways.
In one project, the Foundation provided a one-year, no-interest loan to Health-e-cITi, one of four federally funded Health Information Exchanges (HIEs) in New Jersey. HIEs are organizations within a region that enable healthcare institutions to share patient information across hospitals, clinics, and practitioners. HIEs provide data that policymakers need to analyze the health of the region’s population and make good health policy decisions. Health-e-cITi’s member hospitals and clinics serve many vulnerable residents of Essex, Hudson, and Passaic counties. The Foundation’s loan allowed Health-e-cITi to carry out its work until the federal Office of the National Coordinator for Health Information Technology (ONC) released Health-e-cITi’s funding allocation. As part of its ongoing grant to the Camden Coalition, The Nicholson Foundation is helping the Camden HIE extend its work to surrounding suburban hospitals and helping the Trenton HIE develop and grow.
In another initiative, Nicholson is exploring opportunities to promote electronic health records among behavioral health providers. Encouraging these providers to adopt electronic health records will complement their growing use by other types of providers. In addition, it will help ensure that all the providers who care for a particular patient can share information and collaborate to provide optimal care that benefits the patient’s overall physical and behavioral health.
Another way the Nicholson Foundation supports health information technology is by having a representative serve on the Board of the New Jersey Health Information Technology Extension Center (NJ-HITEC), a federally funded Regional Extension Center. The Center helps New Jersey primary care providers adopt and implement electronic health records systems and become meaningful users of these technologies.
Supporting Integration of Behavioral Health into Primary Care and Strengthening Behavioral Health Treatment
About 25 percent of all primary care recipients have diagnosable mental health disorders, and primary care practitioners provide more than half of the mental health treatment in the United States. However, many people with mental health disorders—some estimate as many as 50 percent—remain undiagnosed.3 Data show that people with severe behavioral health disorders live about 25 fewer years than those without these disorders.
As in other states, many of the patients treated by New Jersey’s community health centers have behavioral health problems as well as physical health conditions. These problems are often undiagnosed and untreated, and if treatment does occur, it is often not coordinated with the physical health treatment. By not treating the whole person, the effectiveness of both types of care is diminished. A heightened emphasis on providing high-quality, coordinated care for these complex and costly patients is likely to improve their mental as well as physical health outcomes and reduce overall costs. The New Jersey Primary Care Association (NJPCA) represents all of the State’s 20 community health centers, which provide care to more than 400,000 poor and low-income residents. The Nicholson Foundation is funding the NJPCA to help two community health centers develop a model of care that integrates behavioral health and primary healthcare services. This 18-month pilot project promotes greater information sharing, better care coordination, and improved patient outcomes. The NJPCA has created an advisory group and peer-to-peer learning teams to coordinate project activities. The teams also orient and train staff and disseminate project information to other community health centers in New Jersey. The project’s integrated care model includes screening and assessment to identify patients with behavioral health problems, a clinical care manager to coordinate care among primary care and behavioral health providers, a designated behavioral health provider, and a patient registry to track appointments and clinical outcomes.
The Network for the Improvement of Addiction Treatment (NIATx), based in Madison, Wisconsin, helps treatment programs improve access to—and retention in—addiction treatment. It does this by helping programs improve their service delivery processes. The Foundation is funding an initiative with NIATx and the New Jersey Division of Addiction Services (DAS) to establish two regional collaboratives for 20 providers that will institute NIATx’s evidence-based Process Improvement Model. The project will help DAS and their participating agencies improve the quality of their services so that more New Jersey residents remain in and complete addiction treatment.
A third Foundation-supported project is built on evidence that employment is the single biggest predictor of long-term recovery from addiction. Connecting recently released ex-offenders to addiction treatment and employment significantly reduces recidivism. However, traditional employment services available to this group in New Jersey have rarely succeeded in helping ex-offenders obtain and retain jobs. The Nicholson Foundation addressed this problem by, once again, linking funding to outcomes. The Foundation contracted with Blessed Ministries, Inc. to place into employment job-ready individuals with significant substance abuse disorders who were enrolled in the State’s largest residential substance abuse treatment program or involved with the Essex County Drug Court. The contract stipulated that funds would be paid only when individuals were retained in employment for more than 30, 90, or 180 days.
Over the course of the grant, more than two-thirds of program participants remained employed for at least six months, and more than half of those placed into jobs obtained employer-sponsored benefits, including health insurance. When the initial grant ended, the project was continued by another foundation with matching funds from Nicholson. Nicholson also funded a similar program for Newark’s recently released violent and non-violent offenders, many of whom have substance abuse problems. Taken together, these initiatives have placed into employment more than 600 individuals with substance abuse disorders or ex-offenders with felony convictions. The initiatives have helped improve the efficacy of addiction treatment and show that ex-offenders with felony convictions and addiction histories can successfully rejoin their communities.
Improving Access to Healthcare Benefits and Services
Many residents of urban areas in New Jersey lack access to primary care for their ongoing health needs and for preventive care. This is due to a relative paucity of primary care providers in New Jersey’s municipalities as well as to a lack of health insurance. The result is that residents—both the uninsured and the insured—rely heavily on hospital emergency departments for their care. Nicholson is supporting a number of projects aimed at helping vulnerable populations access the healthcare system and obtain the ongoing services they need.
One of these populations is newly released offenders who have serious medical and/or mental health problems. It is estimated that about 21 percent of individuals incarcerated in New Jersey have such poor health that they are unable to work and are considered disabled. Enrolling this group in Medicaid so they can maintain the care they received while incarcerated is critical to a successful transition from the criminal justice system to the community. However, New Jersey residents are not eligible for Medicaid if they are single and have a “controlled dangerous substance (CDS)” conviction. The only way for these disabled ex-offenders to access Medicaid is to first obtain Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI). However, the application process for SSI/SSDI can be complicated and difficult to navigate for this population. To facilitate the application process, the Foundation is funding Policy Research, Inc., to use SOAR (SSI/SSDI Outreach, Access and Recovery). This strategic planning, training, and technical assistance approach streamlines and expedites the SSI/SSDI application process and significantly improves acceptance rates. The approach is being applied in Bergen County to disabled individuals leaving jail and in Mercer Country to that same population as well as to disabled individuals who are chronically homeless.
The Foundation also provides grant support to Newark Now’s Financial Empowerment Center. The Center screens and refers individuals and families for multiple benefits, including health benefits, using a specially designed software program. It also follows up to ensure that clients obtain the benefits for which they are eligible.
In a third initiative to improve access, the Foundation is seeking to address prematurity and/or low birth weight among newborns in Newark. These problems are devastating for families and very costly to Newark’s medical and human services delivery systems, both in the short-term around the baby’s birth and in the long-term as the child enters the school system. Foundation staff have worked with the Newark public school system and some of the City’s healthcare providers to connect pregnant teens and women to prenatal care. In addition, staff are exploring a number of other possible approaches to increase access to and regular involvement with prenatal care.
New Jersey: A Leader in Healthcare Reform for Vulnerable Populations
Multiple stakeholders across New Jersey—healthcare providers, government agencies, Medicaid managed-care companies, community-based organizations, individuals, and Nicholson and other foundations—are coming together to seize the opportunities presented by healthcare reform. These stakeholders understand that addressing the healthcare needs of vulnerable families and individuals is critical for New Jersey. They further recognize that success can free resources for other important programs that would improve the lives of all State residents. They are sharing information, building strong partnerships, and showing a willingness to explore entirely new territory. They are identifying and encouraging innovative solutions to New Jersey’s challenging healthcare problems.
Their efforts are already bearing fruit, perhaps nowhere more so than in the Medicaid ACO Demonstration Program. This legislation passed the New Jersey legislature with strong bipartisan support and became law on August 18, 2011. It positions New Jersey to become the first state in the nation to develop ACOs for Medicaid consumers, a promising strategy for serving this population more effectively. New Jersey—the state that ranks middling to last on numerous healthcare indicators—is now leading the nation in healthcare reform for vulnerable populations. There is still much work to be done, but emerging and ongoing efforts are already supporting sustainable systems changes that are resulting in reduced costs and improved health for many New Jersey residents.
Summary prepared: 2011
 The Commonwealth Fund Commission on a High Performance Health System. Aiming Higher: Results from a State Scorecard on Health System Performance, 2009. New York (NY): The Commonwealth Fund, 2009. http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report...
 The Dartmouth Atlas Project. The Dartmouth Atlas of Health Care. Hospital Care Intensity Index, Last Two Years of Life, by Component. Lebanon (NH): The Dartmouth Institute for Health Policy and Clinical Practice. Accessed October 18, 2011. http://www.dartmouthatlas.org/data/table.aspx?ind=6
 U.S. Department of Health and Human Services (HHS). Report of a Surgeon General’s Working Meeting on the Integration of Mental Health Services and Primary Health Care. Rockville, MD: HHS, 2001. http://www.ncbi.nlm.nih.gov/books/NBK44335/pdf/TOC.pdf. Also see: Bazelon Center for Mental Health Law. Primary care providers’ role in mental health.