For Horizon and partners, pandemic has only strengthened resolve to fix health issues around social determinants

The rules limiting social interactions have helped the state battle the COVID-19 pandemic.

But the strict guidance on social distancing has not slowed the commitment of Horizon Blue Cross Blue Shield of New Jersey to attack the social detriments to health.

The company has launched Horizon Neighbors in Health, a $25 million program in which Horizon is working with community partners, in an effort to improve health care among the state’s most vulnerable populations — communities that have been hit hardest by COVID-19.

Horizon BCBSNJ
Valerie Harr of Horizon Blue Cross Blue Shield of New Jersey.

Valerie Harr, who leads the initiative as Horizon’s director of community health, said the company has been committed to the program despite the restrictions that have come with the state’s shutdown, many of which still exist today. In fact, Harr said the pandemic gave the partners a greater understanding of why a program such as this needs to exist.

“We all agreed, especially when we started to see how the virus was disproportionally impacting the African American community and the communities that we were trying to address with our program, that the program was more important than ever,” she said. “We all collectively said, ‘We have to move forward.’”

The need is there.

Horizon officials say studies have shown that social determinants of health can account for as much as 80% of a person’s overall health. These factors have become even more critical in light of the COVID-19 pandemic, as individuals whose access to services and care was challenging in the best of circumstances now face even greater challenges.

Horizon Neighbors in Health, established as a three-year program, is the most comprehensive program ever created in New Jersey to address social determinants of health, officials believe.

Horizon is partnering with Atlantic Health System, Hackensack Meridian Health, RWJBarnabas Health, the Trenton Health Team, University Hospital and St. Joseph’s Health on the program — which follows up on the 400-person pilot program the company ran in Newark in 2017.

The reach is extensive.

The Horizon Neighbors in Health demonstration project will engage members living in 70 ZIP codes across 11 counties (Bergen, Essex, Hudson, Mercer, Monmouth, Morris, Ocean, Passaic, Sussex, Union and Warren), the company said.

And, in addition to being in some of the state’s biggest cities — Newark, Jersey City, Paterson and Trenton — the program also is focused on members who live in suburban communities, such as Toms River, Keansburg, Morristown or Denville.

Allen Karp, executive vice president for health care management and transformation at Horizon, said the Newark pilot was a game-changer — and made the company want to expand the program to more neighborhoods.

“It provided strong evidence that, working together, a health insurer and a health care provider could successfully intervene to address social determinants, improve health and reduce the total cost of care for an individual,” he said. “The lessons learned in Newark are being scaled and deployed in multiple communities across New Jersey to engage 24,000 Horizon members over the next three years.”


Horizon Neighbors in Health could give Horizon the data it has long thought existed: That social determinates to health — everything from food insecurity to nutrition, to mental health and substance abuse issues, to education level and even the ZIP code in which you live — are a huge factor in a person’s individual health, Harr said.

“It will establish a body of data that we expect will demonstrate both the health and financial benefits of using the University of Pennsylvania’s Community Health Worker model to deliver an individualized intervention connecting our members with resources that address their non-health care needs,” she said.

Harr said the community health workers are the key to the program’s success.

They will be hired by the local health partner with a grant from Horizon and trained by the Penn Center for Community Health Workers. There, the community health workers will learn how to work with their patients, identify their needs, connect them with services and provide information that helps members improve their own understanding of health and how to use their insurance benefits to achieve their personal health goals.

The community health workers will use NowPow, an online platform that maintains an up-to-date inventory of services available from local social, nonprofit and community service organizations. The platform enables them to connect members to needed services, track utilization, document outcomes and ensure participants are getting the assistance they need.

And, while the training is important, Harr feels the fact the community health workers come from the communities where they will be working, will prove to be equally as important in their ability to have success.

“I can’t emphasize enough that it really is that relationship, that trust that’s built between the community health worker, that makes the difference,” she said.

It starts, Harr said, with the fact the community health workers are schooled in the area more than medicine.

“The community health community health workers are nonclinicians — and that’s intentional,” she said. “They’re not nurses, physicians. They may not have a college degree. But they are natural caregivers — the people you turn to when you need a good neighbor, someone from your church who does a lot of volunteer work. They are helpers. They know how to listen.”

That’s important, Harr said.

Harr said the initial meeting — which is now a call — is meant to get information. But it’s done in a different way.

“It’s not just a survey and checking off boxes,” she said. “It’s a conversation to cover about 20 different kinds of issues: Does the person need assistance in food insecurity? Is there housing, instability? Do they need mental health or substance use disorder treatment? Do they need access to primary care? Are they have trouble managing their medications? Are they feeling socially isolated? Is there a potential domestic violence happening?

“This is key: It’s not a survey, it’s a conversation.”

One a member may need time to warm up to, Harr said.

And that’s OK, too.

“The initial conversation could be just five minutes — or it could be an agreement to call back tomorrow,” she said. “We are trying to build a rapport. And I’ll keep emphasizing this: It’s about building a trusted relationship.”


Harr said Horizon and its partners had been working for more than a year to prepare for the launch of Horizon Neighbors in Health this spring.

“We spent the better part of a year planning, designing, building relationships with partners, selecting some vendors that we want to work with,” she said. “It wasn’t just, ‘Hey, let’s embed community health workers’ or ‘Let’s give these systems money.’ It was really thoughtful planning and sitting down with each of these partners and collaborating, working on workflows and training.”

Horizon said it identifies potential program participants using advanced data analytics that detect those members whose health history indicates an elevated or increasing level of risk for poor health. Horizon and its local partner organization then reach out to explain the program and its benefits and invite members to participate at no cost.

The outreach, Harr said, is specifically geared to the program.

“It’s not the type of program where you say, ‘Come sign up if you’re interested,’” she said. “We’ve used our data and we’ve used non-claims data. We’ve used different sources of pulling census data and other sources of data to identify not only the geographies that we want to focus on, but also the numbers that we are predicting have been higher cost, higher risk — and are expected to continue to be high and rising risk.”

Tracy Parris-Benjamin, Horizon’s director of clinical design, community health, said the need has never been greater. And COVID-19, she said, is bringing more issues to light.

“The community health workers are not only helping connect those members with the right social services, they are helping them deal with the added strains and stresses being created by the COVID pandemic,” she said.

Horizon Executive Chairman Kevin Conlin said Horizon Neighbors in Health represents a new reality and a new way of looking at health care as it focuses on whole-person care.

More importantly, Conlin said, the program maintains the company’s longstanding mission.

“At its core, our mission is to empower our members to achieve their best health,” he said. “That’s what we have stated and put out there that that’s what we that’s what we stand for. This program is very directly connected to the concept of wellness and, specifically, to some social circumstances that serve as barriers to wellness and a healthy lifestyle.”

The program is proving to be a savings success, too.

“The Newark model showed a relatively modest investment which was deployed in a very personal way, and it yielded some significant improvements in heath of the participating members,” Conlin said. “It increased their engagement with health and improved their health care experience. And, importantly, while it did that, it also lowered the total cost of care.”

Conlin said all of these reasons were why the community was determined to continue the Horizon Neighbors in Health in the face of the pandemic.

“The teams have really stepped up and that’s been very effective,” he said. “You can see we’re making significant progress in this.”

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