Automated Central Intake Workflow in New Jersey
SPECT provides NJ state agencies with the ability to monitor existing programs and plan for future expansion using data to drive decision making. Working with the Department of Health, the Department of Children and Families and local agencies across NJ, FHI expanded the PRA system into a central intake resource for pregnant women in all 21 counties of NJ. SPECT supports the triage of clients by central intake hubs to appropriate home visiting or other community based programs using data from the PRA or the Community Health Screen (non-clinical screen).
The PRA enables prenatal providers to indicate a referral need with a simple selection in the care plan. This triggers an e-referral to the central intake program in the patient’s home county. SPECT then documents all contacts -from referral to enrollment. Local partner agencies update their inclusion of patients in services and this is shared with prenatal partners to prevent duplicative referrals.
Statewide replication of electronic screening and referral tool
The PRA tool is a universal screening tool used by prenatal providers and managed care organizations across New Jersey to identify the risk factors affecting pregnant women. It gives providers the opportunity make referrals to services based on a patient's specific needs. FHI was engaged early in the project, providing expertise in the areas of maternal child health and data management.
FHI serves a leadership role in the statewide implementation of the PRA, supporting the project through provider outreach, marketing, training and technical assistance. Staff provides ongoing support, including training of new and existing users. FHI is also responsible for maintaining the program’s IT infrastructure.
Case management, consumer education, provider training, and policy development
MQC is a free smoking cessation program available to pregnant and parenting women in New Jersey. It provides case management support for mothers looking to quit and teaches the skills needed for long-term success.
As a part of FHI, MQC helps build healthy communities by working to reduce secondhand smoke and train physicians on implementing the model to their patients. Established to serve mothers in Southern New Jersey, the program became so successful that in 2014 it expanded statewide. MQC is a great example of how FHI was able to nurture a program with a local focus and grow it into something with a statewide impact.
Quality assurance monitoring, provider recruitment & training, technical assistance
Although FHI is best known for its expertise in data management, we also have strengths in areas such as project coordination. This is why the State of New Jersey chose FHI to help roll out first the Vital Information Platform electronic birth certificate system in 2015 and then the new VERI data system in 2021. For these projects, FHI was tasked with conducting quality assurance, hospital training and provider outreach. Our main goal was to bring all the hospitals in the state up-to-speed on the new platform and ready for implementation.
Collaborative, cross-sectional effort aimed at focusing community engagement on available evidence-based interventions to reduce premature birth rates in New Jersey
Guided by data, New Jersey’s Prematurity Prevention Initiative focuses on supporting the diverse landscape of mothers in New Jersey who have premature birth experiences or demonstrate a motivation to prevent early birth experiences.
The Prematurity Prevention Initiative focuses its efforts on interventions with the most significant potential to reduce the number of babies born too soon in New Jersey. The initiative is centered around preterm birth & maternal and infant mortality, specifically in Black communities, which face high rates of complications and death disproportionately compared to their counterparts.
Logs all case management services, including assessments, attempted and successful contacts, service referrals, and education provided to participants
NJCHART is utilized by Healthy Women Healthy Families Community Health Workers statewide. The purpose of the assessments is to ensure critical information is collected from all enrolled participants to guide service referrals, education, and case management planning and to collect data necessary to demonstrate the impact of the program on the well-being of women and families and on birth outcomes.
Assessments are completed at intake, after the birth of a child, and every six months. Additionally, information about the services specifically targeted to women in cities with high rates of Black infant mortality is also collected in NJCHART. These include participation in centering groups, doula services, services for fathers, and breastfeeding support services.
System development, technical support
In 2021, the Howard County, Maryland Police Department contacted Family Health Initiatives requesting assistance in the creation of a data system for its full-time Mental Health Section, which is staffed with four full-time employees, including three sworn police officers and a civilian Licensed Clinical Professional Counselor. The section receives referrals from Howard County police officers for mental health crises, suicides and suicide attempts, and emergency petitions. Staff provide follow-up support for both individuals and their family members, including making referrals and ensuring appropriate resources are being provided.
The FHI system includes an intake form, encounter form, ability to flag high-risk clients, a real-time listing of new encounters, and outcome-based reporting. FHI hopes to expand the CONECT model to other police departments with similar community outreach divisions.
System development, technical support
The Volunteers of America Delaware Valley Navigator Program connects individuals in need to critical social services to address short and long-term stabilization. Services range from case management, housing assistance, job placement, and legal assistance/advocacy to substance abuse and mental health referral, treatment referral, and identification assistance. The Navigator program serves individuals across South Jersey, including Atlantic, Cape May, Camden, Mercer, Burlington, and Tri-Counties (Cumberland, Gloucester, and Salem Counties). Additionally, VOADV’s Safe Return Program offers similar services, but focuses specifically on individuals returning to society within years of being incarcerated.
FHI provides Volunteers of America Delaware Valley with a client referral tracking and case management system utilized by both Volunteers of America Delaware Valley staff as well as local law enforcement throughout the South Jersey region. This robust system includes a general intake form for individuals eligible for either the Navigator or Safe Return programs, and the ability to prospectively follow this transient population as their needs change over time. In addition, utilization of the system results in more efficient communication between outreach staff and police officers in the field.
RFP design, research
When the Salem Health and Wellness Foundation needed assistance in addressing the high teen pregnancy rates in Salem County, they turned to FHI. Specifically, the foundation needed help with educating its Board of Directors on the factors driving teen pregnancy in their area. We also designed a Request for Proposal to identify potential evidence-informed programs to address the problem.
Our first step was to analyze the data on teen pregnancy rates in Salem County. We then researched best practices for identifying appropriate strategies for working with that population of young people. Challenges in this conservative, rural community included identifying the most effective way to engage parents and community leaders and designing messages in line with the community’s social norms. This research gave us the footing we needed to help the Foundation target programs with the highest likelihood of success.
Community needs assessment, survey design / administration / analysis, coalition building
For nonprofit hospitals to maintain the 501(c) 3 status, they are required to perform an assessment exploring the health and wellness needs of the communities they serve every 3 years. When South Jersey Healthcare (now known as Inspira) began this process in 2011, they sought out FHI for help. This two-year consulting project began with the design, administration and analysis of focus groups with key stakeholders and concluded with a comprehensive community survey. Staff worked closely with hospital personnel as well as a community advisory group. Emphasis was placed on engaging minority and hard-to-reach populations to obtain a more comprehensive and accurate profile of the community. FHI prepared a final report and conducted presentations throughout the county on its findings.
Wipe Out Lead - In 2004, FHI was selected to be the grant administrator for a statewide program designed to prevent childhood lead poisoning. FHI staff was responsible for distributing lead testing kits to pregnant women throughout the state, providing outreach to consumers and professional education for healthcare providers. We also tracked test results, provided information concerning abatements and performed follow-up with at risk families.
Shaping NJ - Shaping NJ is a New Jersey Department of Health initiative with the goal of preventing obesity through promoting nutrition and physical activity. When Shaping NJ was founded, the DOH reached out to FHI for operational and organizational assistance. We provided them with employee management (hiring, supervision, and benefits), production of marketing materials, administration of professional conferences as and provider training.
East Orange Healthy Start (EOHS) - EOHS is a federally funded program charged with reducing the infant mortality in the East Orange community. FHI was engaged to evaluate the program and provide technical support for the implementation of the Client Health Record Information System (CHRIS). Through CHRIS, EOHS was able to gather real time information to support the project's assessment of success based on the federal reporting measures.