Prior to joining THT, New Jersey native Natalie Terens, MPH, worked closely with clinical staff and leadership on quality improvement and population health initiatives as the Performance Improvement Project Manager at Union Health Center in New York City. Former Paramedic Ernie Morganstern, MPA, designed and implemented new models of care prior to joining THT as Vice President for Care Management at Complex Care Solutions. He supported his team in the design of a web-based platform for care management assessment, planning, documentation, and reporting activities. As members of THT, Terens and Morganstern brought their varied experience in healthcare to assist the Trenton community in building strong bridges to care by addressing the medical, social, and environmental factors that contribute to community health.
Trenton Health Team (THT) has a strong history of collaborative efforts aimed at improving health within the greater Trenton community in New Jersey. Data-sharing among partners has been integral to THT’s work. THT operates the Trenton Health Information Exchange (HIE), providing healthcare practitioners access to an integrated patient record in real time to support treatment decisions and strategies. NowPow, a social services technology platform connects people to community resources to address their chronic and social conditions by making tracked referrals. Using the system, clinical staff, including social workers and case managers, can screen a patient for social determinants of health and generate a curated list of resources based on the patient’s geography and needs. The NowPow-HIE integration is the first of its kind.
In this episode, Podcast host Peter Eckart is joined by Trenton Health Team (THT)’s own co-directors of Population Health, Natalie Terens and Ernie Morganstern to discuss the integration of the NowPow Screening tool and Trenton’s Health Information Exchange (HIE). Natalie and Ernie also build on ideas brought up in THT’s compelling case study, “A Holistic Approach to Social Services,” which can be found here.
- Learn more about the Trenton Health Team
- Read the DASH Case Study on Trenton Health Team: A Holistic Approach to Social Services
- Dr. Caroline Fichtenberg, Managing Director at SIREN (Social Interventions Research & Evaluation Network), catalyzes high-quality research that advances efforts to address social needs in healthcare settings. Her work is mentioned at 21:55. Watch her podcast episode here.
- Engage with the same questions Ernie and Natalie considered in their process, here.
Takeaways from the Interview
In the words of Natalie and Ernie…
1. The collaboration of multiple varied community-based, nonprofit and faith-based organizations drives this work.
“Our core work is bringing varied stakeholders to the same table to advance health. So, we naturally go to solutions where we are bringing different social service organizations, community based organizations, and faith based organizations with the healthcare delivery operations folks that are ordinarily part of the conversations. We wouldn’t do it any other way.”
– Ernie Morganstern
2. It is methodologically supported that ‘custom-fitting’ SDOH tools to your community’s needs is better in the long run for your target population.
“The individual questions that are in our screening tool are clinically validated as individual questions from different tools but we really cherry picked based on what we felt was appropriate for the community.”
– Natalie Terens
3. Understanding a patients’ social determinant needs is an essential aspect of determining their holistic care plan.
“The social needs screening tool and the history of contacts around referrals and individual needs sent out to an organization lives physically in the same area in the Health Information Exchange (HIE) that a doctor would go to look at your chest x-ray or your abdominal ultrasound. Right underneath those documents, which are of critical importance, is another one, which shows all your social determinants needs that were identified in your last system. We really feel that’s of critical importance in the understanding of the holistic patient and getting them the care that they need.”
– Ernie Morganstern