The program addresses social determinants of health (SDoH) needs among members by making the most of its partnerships with health care provider organizations, community health workers, and a community referral platform.

After launching its pilot SDoH program in April 2017, Horizon Blue Cross Blue Shield of New Jersey is aiming to further target members’ socioeconomic needs through their expanded program, Horizon Neighbors in Health, according to the Horizon 2020 progress report.

The original pilot program targeted about 1,000 members with SDoH needs in four Newark ZIP codes to connect them with social, community, and health care resources. The program achieved a 25 percent reduction in total cost of care and a 60 percent increase in behavioral health treatment or utilization.

Horizon Neighbors in Health launched in April 2020 amid the COVID-19 pandemic, which further underscored the state’s need for the larger program. Among New Jersey residents, 39 percent cannot meet basic needs and 1 in 10 are food insecure.

The Horizon Neighbors in Health program targets members across 15 counties and 127 ZIP codes and consists of 10 partners, including eight health care provider organizations; Penn Medicine which provides training to community health workers (CHWs), and NowPow, an online platform to connect members with community-based resources.

The SDoH model uses CHWs and personal health assistants to address critical elements that impact a member’s health but fall outside the traditional care delivery model of home care, primary care, behavioral care, inpatient care, specialty care, and pharmacy.

Key components of the Horizon Neighbors in Health program include:

  • A network of up to 60 CHWs, who are hired from the communities they will serve, and personal health assistants who act as trusted advocates for program members and help identify critical elements that impact a member’s health
  • A training and certification process provided by Penn Medicine for all CHWs, managers, directors, and coordinators
  • Predictive analytics using purchasing information, census data, marketing engines, and medical claims information to best identify communities with significant SDoH needs
  • A collaborative learning network for program system leads to meet quarterly to foster collaboration and share best practices
  • The use of NowPow to connect members with community-based resources, ensure quality referrals, and provide support throughout the referral process

“Ultimately, the goal of Horizon Neighbors in Health is to address social determinants of health barriers that impact social, emotional and physical health, in turn guiding our members through these difficult times and ultimately empowering them to live their best lives through increased availability of options and information,” wrote report authors. “We want this program to serve as a model for the rest of the nation and hopefully expand to include every corner of the state.”

The program’s first year results were promising:

  • A total of 2,588 members enrolled
  • 730 members (28 percent) have graduated from the program
  • Top needs identified include financial stability, food, and basic health care
  • Leading referrals service type include food pantries, utility payment assistance, and rent and mortgage payment assistance

Horizon’s goals for the program in 2021 include enhanced community engagement, COVID-19 and vaccine education, collaboration with community-based organizations and New Jersey’s Department of Health, program expansion to additional counties, increased provider engagement, ongoing training for CHWs, and increased enrollment.