Community health collaborative facilitates health system and community change to address unmet medical and social needs in New Jersey

Four New Jersey Regional Health Hubs (Camden Coalition of Healthcare Providers, Health Coalition of Passaic County, Healthy Greater Newark, Trenton Health Team) support community and clinical care linkages across various sectors. Regional Health Hubs have been successful in engaging various stakeholders and convening coalitions and programs to address long-term health conditions. We present a case study of community and clinical care integration through the experience of a multi-faceted, community-based initiative in Trenton, NJ, focused on supporting patients with diabetes and barriers they are facing.