Published on NJ.com by Jeffrey Brenner, Gregory Paulson and Stephen Schneider

Most people have received fragmented, disjointed care at some point in their health care experience.

For some, this lack of coordination may not only be costly but dangerous as well. Take for example, Jane (a real case here in New Jersey), a middle-income woman in her early 30s. In 2011, she went to the emergency room 102 times, was admitted 54 times and received 147 CT scans, resulting in a lifetime radiation amount that increased her likelihood for cancer. Once a group of physicians came together to conference on her case and visit her in her home, they learned that she had a severe anxiety condition, which drove much of her utilization.

Now imagine Jane’s story coupled with chronic health conditions, substance-abuse issues, weak social networks, poor transportation access and limited financial means. For patients with the most complex health and social needs, failures in the health care delivery system are even more profoundly felt.

In 2014, New Jersey took important steps to address the fragmented, disjointed health care system by certifying three Medicaid Accountable Care Organizations – known as ACOs – in Trenton, Newark and Camden.

These community-based Medicaid ACOs are the only entities that link local, competing stakeholders in a given community for the purposes of improving people’s health and transforming health care delivery. Because ACOs are grounded in their communities, each is able to rely on their community’s data and needs to develop the most appropriate programming. Through the innovative use of integrated data as the foundation for the work, ACOs help coordinate care for all patients and target individuals experiencing expensive and inefficient “super utilization” of the hospital system.

Sparking local innovation, ACOs have advanced social-service solutions for their complex patients, such as supportive housing. For example, the Camden ACO, with the support of the state, launched a Housing First program. Modeled after Trenton’s successful Housing First program, the Camden organization is convening local housing and behavioral-health service providers to target supportive housing to high-cost, high-need patients who are also homeless.

The preliminary results of this program have been staggering, with a 40 percent decrease in expensive hospital utilization for participants.

Although Medicaid ACOs are relatively new models, in New Jersey and other states, longer-established ACOs across the country have shown significant promise, many of which have been supported by upfront investments from their states. The Center for Healthcare Strategies reports that Colorado’s ACO-type organizations have reported $77 million in net savings to Medicaid and have demonstrated lower rates of emergency-room visits, high-cost imaging and hospital readmissions. Minnesota has attributed $76.3 million in savings within the first two years of its program, and Vermont reported $14.6 million in savings in its program’s first year.

New Jersey has been recognized nationally for its innovation in developing this model. The state’s leadership, support and investment in the ACOs has been vital in signaling the tremendous potential of the work the ACOs have begun – and need to continue. The state has been integral in the development of the ACOs under a three-year demonstration project. For ACOs to have a chance to accomplish what they were created to do, we encourage the state to continue its support of the project.

Most important, all New Jersey residents, especially patients with complex health conditions, will have the potential to gain in quality of health care services, improved health outcomes, and savings on health care delivery costs.