The New Jersey Health Care Quality Institute (NJHCQI) released on Tuesday a road map to build on the potential of community-based coalitions to improve care for people with complex health and social needs.

The coalitions, originally known as Medicaid Accountable Care Organizations (ACOs), advance innovations that address social barriers to health and well-being — and enable local governments, nonprofit organizations, and health care providers to work together to improve the overall health of a community.

According to NJHCQI, the road map creates a vision for the state-certified Medicaid ACOs in Camden, Trenton and Newark, and one “look-a-like” Medicaid ACO serving Paterson, to evolve into a model of coordinated Regional Health Hubs (“Hub”).

This, says NJHCQI, will enable continued growth, innovation and opportunities to achieve even greater success across the state of New Jersey. The current Hubs are: The Healthy Greater Newark ACO; the Trenton Health Team; the Camden Coalition of Health Care Providers; and the Health Coalition of Passaic County. The Road Map also outlines how other communities can develop Hubs.

“Health and well-being are about more than access to health care services,” said Linda Schwimmer, president and chief executive officer of the NJHCQI in a statement.

“Good health is also about social supports, housing, safety, and access to nutritious food. This Roadmap outlines how together we can continue to build on the success of Medicaid ACOs through the Regional Health Hub model,” said Schwimmer.

Medicaid ACOs in New Jersey date back to 2011, when the Quality Institute, with support from The Nicholson Foundation, partnered with many community organizations and health care systems working to improve care and living conditions for people in underserved areas in New Jersey.

The roadmap for the future of these ACOs is available here.

The Hub model outlined in the roadmap embraces the successful elements of ACOs: bringing together competing interests, analyzing patient-level data to inform care decisions, and serving as a hub for community organizations and health care providers to work together to achieve the population health goals of the state.

The ACOs were created with state and foundation funding under a demonstration project that is ending. The Hub model builds on the ACOs’ years of experience working with complex patients and will provide strong data analysis that will support patients even if they move to different communities.

Trenton Health Team, a Medicaid Accountable Care Organization, welcomed the NJHCQi road map.

Gregory Paulson, executive director of THT said that regional partnerships are making a real difference in the lives of low-income residents and reducing health care expenses for taxpayers.

“In fact, New Jersey is rapidly becoming a national model for how communities can come together to tackle our shared health challenges,” said Paulson.