Horizon Neighbors in Health Program Helps At-Risk Members in Camden

Jubril Oyeyemi, M.D., a Primary Care Physician in Camden, often treats patients who are dealing with life problems too big for a doctor alone to solve.

“The population we serve has some of the most complex daily living needs,” Dr. Oyeyemi says. “They're facing housing instability or homelessness. Transportation is another big problem. Social Determinants of Health (SDoH) shape health and wellness in a way that goes way beyond the walls of the primary care office.”

Dr. Oyeyemi is the Medical Director at the Camden Coalition of Healthcare Providers, which partnered with Horizon in April 2020 to launch the Horizon Neighbors in Health program in Camden. The program aims to address SDoH and reduce health disparities to help at-risk members achieve good health. Since it began, the program is bringing hope and practical solutions to people facing challenges they see as insurmountable.

“The Horizon Neighbors in Health program has been remarkable,” Dr. Oyeyemi says. “With the Camden Coalition and Horizon working together, we're able to identify the needs of high-risk members and walk alongside them using a coaching model, to show them how to help themselves and meet those needs in a way that's sustainable.”

How Horizon Neighbors in Health Works

Dr. Oyeyemi works with an interdisciplinary team of nurses, community health workers and social workers to help at-risk members who have been identified and referred to the Neighbors in Health Program by Horizon. These members are dealing with various SDoH issues that impede their access to health care. In addition to housing and transportation issues, SDoH can include financial stability, employment, education, food, childcare, behavioral health and substance use.

The community health workers live in the community and receive special training for the program. They reach out to the identified members and consult with Horizon's Personal Health Assistants, who help members get the care they need by linking members to community resources.

“There's a deeper psychology happening when they connect with members, whether it's over the phone or directly in person. They are very present and use reflective listening and motivational interviewing to help members identify and solve their needs.”

“It should be lauded, when you have an insurer that looks beyond medication and doctors' notes. Horizon realizes that there's a lot more playing a role in the patient's health and well-being,” Dr. Oyeyemi says.

Building Relationships is the Key to Success

Dr. Oyeyemi explains that members often don't realize the impact that SDoH issues have on their health and life.

“Getting them to see that this is a larger problem that has to do with the quality of life and lifespan, and connecting the dots, sometimes is a struggle. And our team does that quite well. We're able to help them in real time.”

Dr. Oyeyemi says the key to the success of the program is in the relationships that are built.

“The foundation of the work we do is how we find the authentic healing relationships between the community health worker and the patients. It's the bond that is forged. It's a big deal to patients to have someone call and follow them along over a certain amount of time,” Dr. Oyeyemi says.

The reach of Horizon Neighbors in Health

In addition to the Camden Coalition, Horizon partners with several other health systems in New Jersey to help at-risk members. The Horizon Neighbors in Health program has shown great success since it began in April 2020. As of October 30, 2021, 6,300 members have been enrolled and 3,145 completed the program.

In Camden, more than 200 people have completed the program as of September 2021. Dr. Oyeyemi expects that the Camden Coalition will meet its goal of helping 300 people by the end of 2021.

He hopes that programs like Horizon Neighbors in Health, which integrates insurers, providers and local community resources to address social barriers to health, will continue to grow.

“I wish more insurers had programs like this to help the community with a proactive approach to wellness instead of reactive. I hope it becomes standard and is replicated all over,” Dr. Oyeyemi says.