Caring Moves the Trenton Community to Action

NJHI 2018: Upstream Action Acceleration Accelerating Action for a Healthy Trenton

Trenton Health Team’s Care Management Team (CMT) provides social, psychological and health care support to Trenton residents with complex health and social conditions, based on referrals from community partners. The team embraces whole-person care, screening for social determinants of health (SDOH) and addressing challenges that impact health and well-being. 

In other words, they care.

In the spring of 2020, as COVID-19 infections were spiking, Trenton Health Team (THT) Nurse Care Manager Cheryl Towns received a call from the Trenton Area Soup Kitchen: a 74-year-old man with a history of heart disease and stroke was walking eight blocks each way for a daily hot meal. 

“This is somebody who worked hard his whole life,” Towns said. “He had no one else to turn to. We help the people who are most vulnerable.”

Towns, who supervises the Care Management Team, alerted Community Health Worker Ashlee Wynne, who reached out to the man and offered not only a ride and much needed assistance but also, kindness.

“I usually would depend on my community health worker at Trenton Health Team for transportation. I felt blessed. . .I was able to lean on them for support when I was feeling hopeless.”

– 74-year-old Trenton resident

“I usually would depend on my community health worker at Trenton Health Team for transportation,” the man said. “I felt blessed. . .I was able to lean on them for support when I was feeling hopeless.”

“Living in a boarding house, with just a hotplate and mini-refrigerator, was causing hardship and worry,” he said. Finding him stable, permanent housing was a high priority for THT. “My greatest fear moving forward is my health deteriorating,” he said. “I have many long-term health issues.” 

Members of the Trenton Health Team’s Care Management Team. From left, Nurse Care Manager Cheryl Towns, Community Health Worker Ashley Wynne and Social Worker Pat Ni’ma-Mohammad. (Photos provided by Trenton Health Team)

Wynne asked THT Social Worker Pat Ni’ma-Mohammad for help finding housing for the client. But low-income senior housing requires residents to provide a valid birth certificate – and this man was born at home in the rural south, with the only record of his birth handwritten in the family Bible.

That didn’t stop “Miss Pat,” as she is called in the community.

Working the phones and navigating state bureaucracy, she enlisted a state legislator whose staff is in the process of obtaining an affidavit of birth for our client. Meanwhile, she was able to persuade the Trenton Housing Authority to consider the birth record requirement fulfilled after the client provided adequate credentials proving his identity. The client recently moved into a Trenton Housing Authority senior apartment – and proudly showed off the keys.  THT’s goal as a Communities Moving to Action grantee is to build a network of community partners with the capacity to help residents resolve health and well-being concerns. This exemplifies how community partnerships can improve the lives of Trentonians with the greatest needs.

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Michelle Ruess
Trenton Health Team