JFK Health - Plainfield Health Connections

What is it?

Plainfield Health Connections (PHC) is a JFK Medical Center initiative whose mission is to improve the health of uninsured and underinsured residents in the greater Plainfield community and reduce health care costs through innovative community health care. This includes reducing avoidable utilization of high-cost hospital and emergency department (ED) services. The program utilizes tactics developed by the Camden Coalition of Healthcare Providers in Camden New Jersey to improve patients’ health by focusing on community development, health literacy education and coordination of existing health and social services programs to address the health needs of the sickest members of the community. Funding for the program was supported in part by a grant from the Johnson & Johnson Community Health Care Fund.

Plainfield Health Connections staff features an advanced practice nurse with a community nursing background and an outreach worker to guide the identified patients to appropriate community-based health care and social services resources as indicated. Health literacy education is provided along with individualized and group visits to improve patients’ understanding of their particular chronic condition and how to manage it. PHC works with community-based resources, such as primary care, pharmacy and nutrition counseling, to coordinate care and develop individualized care plans for each patient.

Unlike a clinic or patient centered medical home, PHC does not provide medical care. The program instead seeks to coordinate existing community-based programs, identify barriers to care that impede each patient’s wellness, and develop a care plan to remove those barriers. Examples of common barriers include: inability to afford patient cost share for health care resources; lack of transportation; language and cultural barriers; lack of awareness of resources available in the community; lack of knowledge about their chronic conditions and how to manage them, and low trust in the traditional health care system. PHC refers patients to community partners to share in the responsibility for improving the health of its patients, including: federally qualified health centers and other primary care providers; pharmacies; housing and transportation resources; and religious and civic organizations.

Who is it for?

Chronically ill uninsured and underinsured residents in the greater Plainfield community. Candidates for the program are selected based on their utilization patterns in JFK Medical Center’s ED in Edison and the satellite ED in Plainfield. Ideal candidates include those who frequently utilize ED services to treat chronic diseases that would be better served in a primary care setting.

Why do they do it?

Chronic conditions present a common set of challenges to individuals and their families, such as: dealing with symptoms, coping with disability, handling emotional impact, understanding complex medication regimens, making difficult lifestyle adjustments and obtaining medical care.

Impact

Plainfield Health Connections is a results-oriented educational and disease management program that increases patients’ knowledge, skills and confidence to manage their chronic conditions. During the first year of operations, the program showed a 67 percent reduction rate in ED utilization, a 56 percent decline in hospital charges for this cohort and 66 percent of participants reporting improved health status as a result of the program.

Contact: Laurie Zalepka
Manager, Corporate Marketing & Public Relations
Telephone: 732-632-1528
Email: lzalepka@jfkhealth.org