NQF continues our series of Q&As with field testing groups with a conversation with Gregory Paulson, executive director of the Trenton Health Team, Inc. (THT), a community-based health improvement collaborative serving New Jersey’s capital. THT is a partnership among two hospitals (Capital Health and St. Francis Medical Center), a Federally Qualified Health Center (Henry J. Austin Health Center), and the City of Trenton’s Department of Health and Human Services. Guided by a 40-member community advisory board, THT works to improve health outcomes at the population level by expanding access to primary care and improving community-wide clinical care coordination, particularly for high-need, high-cost patients.

NQF: How would you describe your community?

GP: Trenton is the capital of New Jersey. It is a significant urban center, with a population of more than 84,000 people. The city struggles with economic, environmental, social and behavioral challenges. More than 26 percent of its population lives in poverty, compared with 11 percent of the population across the state, and the average household income is just $36,662, compared with the state average of $71,629.

A Community Health Needs Assessment completed by THT in 2013 identified a number of critical issues, including behavioral health, safety and crime, and chronic disease—especially cancer, diabetes, and hypertension/cardiovascular disease. Thirty-one percent of Trenton's residents have hypertension, 16 percent have diabetes, and 39 percent are obese.

NQF: What are the two biggest challenges your community faces?

GP: The two biggest challenges are economic and educational. The population has low levels of literacy and academic achievement, limited job prospects, substance and behavioral health issues, and difficulty accessing healthy food, opportunities for physical activity, and basic health and social services. A limited tax base and aging infrastructure exacerbate the situation.

NQF: How has participating in NQF’s Population Health Framework project helped to further the Trenton Health Team's work?

GP: Participating in NQF’s population health project has validated our collaborative accomplishments and has reinforced the importance of data to assess the progress of our efforts. The project also has helped us to learn strategies to strengthen our efforts moving forward. The Action Guide 2.0 will continue to be a valuable resource to track population health in our community, especially in our new capacity as a certified Medicaid Accountable Care Organization.