New Jersey Health Initiatives - A Better State of Health
A Robert Wood Johnson Foundation Program
HCPC Pathways to Success – Working to Improve Access Through Innovative Programs and Advance the Building a Culture of Health: Blueprint for Action in Passaic County

The Health Coalition of Passaic County (HCPC) was founded in 2016 by a grant from The Nicholson Foundation. We are a collaborative effort of 17 Board members and 37 Community Advisory Board (CAB) members from a wide range of community organizations, including Passaic County Food Policy Council partners, who are working to improve the health and quality of life for residents of the Greater Passaic County area by addressing social determinants of health.  HCPC works to align community resources, both clinical and social, to facilitate access for the most vulnerable. Our work is assisted by data access via Saint Joseph’s Health System, the use of the Agency for Healthcare Research and Quality endorsed Pathways Community HUB Model, and the NOW POW technology platform.

The HCPC Pathways to Success program works to improve access and address the complex needs of Medicaid clients. Once enrolled, clients work with the HCPC Community Health Worker (CHW) to initiate specific pathways and connect to existing community resources.  For example, a HCPC Pathways to Success participant may need assistance in obtaining social services related to food or housing. The HCPC Community Health Worker will activate the appropriate pathway, assist the client with each step of the pathway, refer the client to the appropriate community partner, and follow-up with the client until the pathway is completed.

Participants in our program have a 70%-plus engagement rate with our Community Health Worker — a true measure of success when working with a high-need, challenging and transient client population.  All of these tools — the CHW role, CHW training, and effective use of tools to measure and track needs, services, and outcomes (Pathways model, NowPow Technology) are critical in improving access and building a culture of health in our community.

The HCPC Pathways to Success program is working to extend care coordination beyond any one organization.  It enables measurement, tracking, and capacity building within the community through pathway activation, pathway closure, outcome tracking, and, through the NowPow platform’s closed loop community referrals.

For more information about HCPC projects, please visit http://healthcoalitionpc.org/ or contact Kim Birdsall, HCPC Executive Director: birdsallk@sjhmc.org

For more information about the Building a Culture of Health: Blueprint for Action in Passaic County please contact Mary Celis, Director of Health Initiatives, United Way of Passaic County: maryc@unitedwaypassaic.org or visit our Facebook page: @PassaicFood.

 

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Project
Author
Kimberly Birdsall
Organization
Health Coalition of Passaic County