How Regional Health Hubs Can Improve Care for Medicaid Beneficiaries: Lessons from the Garden State

Milbank State Leadership Network
Focus Area:
State Health Policy Leadership

Policy Points

  • The Camden Coalition has used the regional health hub model to improve access to maternity care and behavioral health services and increase uptake of COVID-19 vaccines.
  • Regional health hubs serve as local experts, informing state policymakers about conditions on the ground and shaping initiatives to respond to identified problems in effective ways.

When New Jersey Governor Phil Murphy signed legislation creating regional health hubs in February 2020, he had exquisite timing. The coronavirus pandemic began to sweep across the state that spring, and the new hubs — led by nonprofit coalitions in Camden, Newark, Passaic County, and Trenton — were well positioned to relay information to the capital about the impacts of the pandemic on Medicaid beneficiaries and other residents. Coalition members were able to inform state responses and, with their partners, provide public health guidance and other supports to communities as the crisis unfolded.

The regional health hubs were designed to serve as a bridge between the Medicaid agency and the providers who serve Medicaid beneficiaries in different parts of the state. To guide their work, the hubs operate health information exchanges (HIEs) that collect and analyze health and other data for beneficiaries in their region, helping to identify patterns and unmet needs. They also bring together local health care providers, nonprofits, social service agencies, and consumers to improve access to and utilization of services and to provide feedback on consumer and provider experiences to the state.

In this issue brief, we describe how our regional health hub — the Camden Coalition of Healthcare Providers (Camden Coalition) — has used the model to improve access to maternity care and behavioral health services and increase uptake of COVID-19 vaccines.

The four regional health hubs in New Jersey are the Camden Coalition of Healthcare Providers, the Greater Newark Healthcare Coalition, the Health Coalition of Passaic County, and the Trenton Health Team.

Health hubs must be nonprofits with governing boards that include representatives of local hospitals, federally qualified health centers, independent providers, behavioral health providers, managed care organizations, and/or community-based organizations. They also must have advisory boards made up of community residents.

Each health hub works with the state’s Medicaid office to develop a scope of work that reflects state priorities and local needs. The hubs are also responsible for running health information exchanges (HIEs) and convening local stakeholders. Together, the HIEs contain records on nearly 2 million patients and are used regularly by 2,000 health care and social service providers.

From Medicaid ACOs to Regional Health Hubs

The regional health hubs grew out of an accountable care demonstration New Jersey launched soon after it expanded Medicaid eligibility to include additional low-income residents in 2014. At the time, New Jersey policymakers were looking for ways to improve health outcomes for beneficiaries while controlling costs. The state certified three coalitions — the Camden Coalition, Trenton Health Team, and Greater Newark Healthcare Coalition — as accountable care organizations (ACOs) for a Medicaid demonstration that ran from 2015 to 2018. Like many accountable care initiatives across the country, the goals were to promote collaboration across health care providers, better target services to high-need patients, and control the rate of cost growth.

In Camden and other cities with large numbers of Medicaid beneficiaries, there was clear evidence of opportunities. Medicaid covers more than half of Cam den residents. Some beneficiaries — particularly those whose physical health conditions were compounded by mental health conditions and/or substance use disorders — frequently used emergency departments (EDs), often for non-urgent issues. The Camden Coalition sought to disrupt this cycle. Since its founding in the early 2000s, its staff have specialized in providing intensive, hands-on case management to connect these patients with primary care and other supports.

Participating in the ACO demonstration gave the coalition access to Medicaid claims data, enabling staff to identify both individual needs and population health trends and evaluate programs and initiatives in a more robust way. The ACO demonstration also illustrated the benefits of having a neutral convener in each region to bridge different and often competing health care providers and payers — and of bringing social service agencies and community organizations to the table. As the demonstration wound down, Camden Coalition and its partners successfully advocated to make regional coalitions a permanent part of the Medicaid program.

The designation as a regional health hub gave the coalition and the three other hubs ongoing access to Medicaid data feeds and reliable funding for their work. Their funding is determined through a memorandum of understanding and linked to completion of certain activities. While the funding from the New Jersey Department of Human Services and its Medicaid office does not cover all the hubs’ costs, it provides necessary operating support. Even though New Jersey relies on Medicaid managed care, managed care organizations are not a formal part of the regional health hubs. In the Camden area, managed care organization staff have been invited to advisory meetings, contributed data, and otherwise taken part in pilot projects. For example, several of the hubs, including the Camden Coalition, are participating in Horizon Blue Cross Blue Shield of New Jersey’s Neighbors in Health program, which supports the use of community health workers to screen Medicaid members for food insecurity, financial insecurity, or other problems and helps connect people to support.

Connecting Pregnant People to Supports: New Jersey’s Quality Improvement Program

When people don’t have timely and effective prenatal care, they may experience complications that go unnoticed and they are more likely to have low birth weight or preterm babies, both of which have been linked to infant mortality. New Jersey hospitals can earn incentives for:

  • increasing receipt and timeliness of prenatal visits
  • increasing treatment of severe hypertension among pregnant people
  • reducing maternal morbidity, or unexpected outcomes of labor and delivery that have significant short- or long-term health consequences
  • increasing receipt of postpartum visits, including screening for postpartum depression

Source: Funding Mechanics Protocol, Performance Measurement Specifications, and Data Submission Guidelines for Quality Improvement Program – New Jersey

Identifying Beneficiaries in Need of Support

The HIEs are a foundational element of the regional health hubs, enabling each to identify gaps in care at individual and population levels. Camden Coalition’s HIE includes data from regional hospitals, primary care providers, laboratory groups, and correctional health facilities. It also enables local housing providers and faith-based organizations to access some health information provided the consumer consents. A shelter employee managing medications could access a resident’s health history, for example, while clergy members could be alerted when an elderly parishioner is admitted to the hospital.

Equipped with HIE data, the Camden Coalition has partnered with regional hospitals to design, test, and implement programs that help hospitals succeed under several state pay-for-performance programs, including one focused on reducing maternal morbidity and improving maternal care. In 2021, Camden Coalition staff began running daily reports that flag pregnant people who visit local EDs but have no record of having initiated prenatal care. The coalition shares these data feeds with their partner organizations, which now include four health systems, one federally qualified health center, and one community organization that focuses on perinatal health programming. Patients are assigned to one of these providers based on prior treatment patterns; these providers then call beneficiaries to offer to connect them to prenatal care.

As of June 2022, Camden Coalition and its partners had identified 1,530 pregnant people who visited regional EDs with no record of having visited an OB/GYN — evidence of significant need. Among the 922 people the providers attempted to contact, they reached 518. To help providers engage people who aren’t accessing care, Camden Coalition staff offer coaching and advice about effective approaches. Based on experiences thus far, there’s a clear need for more outreach staff who speak Spanish and other languages apart from English. Clinics could also engage more people if they offered more flexible scheduling practices. OB/GYNs typically don’t schedule appointments until after the first trimester to ensure the pregnancy is viable, but many people need support earlier, particularly those who have experienced a miscarriage, visited an ED, or face barriers in accessing care, such as lack of transportation.

With philanthropic funding, Camden Coalition also gives each participating practice $10,000 to distribute to pregnant patients; most sites use these funds to offer gift cards to help patients purchase things like baby supplies, maternity clothes, or other necessities. Practices have also used the funds to buy blood pressure cuffs, diabetes test strips, and other supplies for Medicaid beneficiaries who might have run out of supplies or face delays in getting prescriptions for durable medical equipment filled. Interviews with staff have revealed that not only do these funds help patients feel cared for, but they’ve also improved staff morale by helping staff bond with patients and feel they’re making a difference in their lives.

Redesigning Services for People with Behavioral Health Needs

Along with incentives to improve maternal health, New Jersey Medicaid’s Quality Improvement Program, a pay-for-performance program, rewards hospitals for improving health outcomes for beneficiaries with behavior al health needs by connecting them with ongoing care for issues such as depression and substance use.

To help hospitals achieve these goals, the Camden Coalition leveraged its experience with its 7-Day Pledge, a citywide campaign launched in 2014 in which staff engaged Medicaid beneficiaries while they were hospitalized to make sure they had a primary care appointment within seven days of discharge. Along with scheduling appointments, staff educated beneficiaries about the value of primary care, offered transportation to visits, and awarded gift cards (funded by managed care companies) to those who attend their visits. A study found that those who attended visits were less likely to have an unplanned hospital readmission.

In 2021, the Camden Coalition launched Pledge to Connect, targeting Medicaid beneficiaries with behavioral health issues who visit the ED at Cooper University Health Care. Such patients are screened for safety issues (e.g., suicide or overdose risk) and then routed to one of two pathways. For patients at lower risk, Camden Coalition staff reach out by telephone and help them schedule behavioral health appointments. For patients with higher needs (e.g., serious mental illnesses), staff from Oaks Integrated Care, a SAMHSA-designated community behavioral health clinic, visit the ED in person to engage people in care.

As of June 2021, more than 1,324 individuals had been contacted, 586 had been engaged, and 245 had accepted behavioral health appointments. To make sure they understand beneficiaries’ experiences, Camden Coalition staff ask what supports they need to stay healthy. Early lessons for the Medicaid program include the need to integrate behavioral health treatment into primary care to make it easier for beneficiaries to access services. Community health workers can also help people navigate the behavioral health care system and find the supports they need.

Serving as a Local Expert

In addition to identifying beneficiaries’ needs and piloting new approaches, regional health hubs serve as local experts, informing state policymakers about conditions on the ground and shaping initiatives to respond to identified problems in effective ways.

This skill set proved valuable as Camden Coalition staff helped community members weather the pandemic. Staff held weekly or biweekly meetings with staff from the state Department of Health, Department of Human Services, and others.

Beginning in the fall of 2020, in anticipation that a coronavirus vaccine might soon become available, Camden Coalition staff partnered with local nonprofits and social service agencies to understand what misconceptions about vaccines were prevalent and what kinds of information people wanted. They conducted 265 interviews, eliciting a wide range of perspectives from people who aren’t often consulted, including those experiencing homelessness and those who use drugs as well as those with complex health conditions, older adults, and families with young children. From these conversations, they learned that Camden-area residents were more hesitant about getting an eventual coronavirus vaccine than was being reported nationally, according to polls at the time. One finding stood out: when asked what might build people’s confidence in a vaccine, large numbers (72%) said they wanted to learn more about it — and the majority (62%) said they would feel more confident if they could discuss the vaccine with their own health care providers.

Next, the organization assessed the readiness of the health care community to answer patients’ questions about the vaccine. They surveyed 150 staff at primary care providers’ offices, purposefully including nurses, medical assistants, community health workers, and front-desk and other administrative staff as well as physicians. The survey found two-thirds of the respondents from primary care practices were likely to engage with vaccine-hesitant patients. Yet three-quarters of those surveyed said they’d never been trained how to do so. To help fill that need, the Camden Coalition and other community leaders developed a free training program for individuals who work in clinical settings to engage patients who express vaccine hesitancy. To date, hundreds of providers have been trained in New Jersey and around the country.

Camden Coalition also made sure that community members shaped the COVID response. When members of its Community Advisory Committee asked to take part in contact tracing but were prevented from doing so because they didn’t have the educational and work experience required by the state, the coalition proposed that they work instead as community ambassadors. Using COVID-relief funds directed to the regional health hubs, eight ambassadors have been trained and hired, going door to door to share information on COVID-19 vaccines and staffing vaccination events; they also liaise with county health officials, pharmacies, and local providers to help them understand residents’ particular needs.


Caption: Camden CoalitionCamden Coalition staff participated in pop-up vaccination events across the city, administering vaccines and providing social service screenings. Community ambassadors helped spread the word of the events throughout the community. Photo credit: Camden Coalition (left and above) and April Saul (right) for the Camden Coalition

Lessons for Other States

The Camden Coalition’s experience as a regional health hub suggests lessons for other states.

Having a neutral convener can bring together different sectors and stakeholders to tackle shared challenges.

The regional health hub creates an infrastructure for convening local health providers, social service agencies, community organizations, and residents to identify problems and pilot new approaches. During the pandemic, large health systems and provider groups worked with national pharmacy chains in their vaccine efforts, while the Camden Coalition was able to partner with locally owned pharmacies to hold neighborhood-based vaccination events.

The hub also enabled the Camden Coalition to engage Medicaid beneficiaries and other residents in delivery system reforms through trusted relationships built over years of field work in city neighborhoods, churches, food banks, shelters, and elsewhere. As the maternal health and behavioral health pilots progress, staff will be measuring traditional health outcomes such as patient engagement and retention in treatment, but they will also ask patients about their day-to-day lives and what matters to them.

Regional health hubs can help states create effective and equitable health policies and improve access and utilization of services by consumers.

Camden’s community outreach during the pandemic, including use of community ambassadors, seems to have built residents’ trust in the public health response: as of late July 2022, uptake of the COVID-19 vaccine appears to have been higher in the city of Camden (where the vast majority of the population identify as Black and/or Hispanic) than in most other states.1

With the public health emergency set to end in May 2023, New Jersey will soon resume the process of redetermining eligibility for Medicaid and disenrolling people who are no longer eligible, risking errors and treatment disruptions. At the request of the state, the Camden Coalition will help facilitate Medicaid redeterminations in several ways, including by surveying providers about how they may respond when their patients lose eligibility or need to reenroll. Their involvement can also ensure the state understands how this policy is affecting beneficiaries.

Building on this work will require participation from and better coordination with Medicaid managed care organizations.

Most Medicaid beneficiaries in New Jersey are enrolled in a managed care plan, but such plans are not formally involved in the regional health hubs’ work. Leaders at the Camden Coalition have begun conversations with man aged care plans about how they might take part in the perinatal health and behavioral health pilots, including by contributing data and modifying their own care management practices based on lessons learned on the ground.

The next iteration of New Jersey’s Section 1115 waiver (now under final review by the Centers for Medicare and Medicaid Services) may strengthen requirements for managed care organizations to identify beneficiaries’ health-related social needs and link them to social sup ports. Managed care organizations could further these goals by taking advantage of Camden Coalition’s HIE, which includes Findhelp, an electronic resource-and-referral platform that enables users to refer patients to food pantries, legal services, and other social services. Camden and other regional health hubs are also well positioned to help managed care organizations and other payers, including Medicare Advantage, contract with community organizations to deliver services to their members.

Looking Forward

Experience to date suggests that regional health hubs are key players in the health care landscape, helping to identify problems and leveraging data and new approaches to solve them.


1. The state’s dashboard showed 81% of people had at least one dose of the vaccine as of July 25, 2022. A Kaiser Family Foundation analysis of data from 36 states found lower first-dose vaccination rates among Black and Hispanic people as of mid-July 2022 (59% and 67%, respectively).