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Health Care Equity

Health Equity2025-05-28T09:29:41-04:00

At CentraState, ensuring health equity is not only a strategic priority – it’s at the heart of our healthcare system. Our team members are invested in the health and well-being of all people throughout our region.

What Is Health Equity?

Health equity means that every person has the opportunity to achieve the healthiest life possible, regardless of race, ethnic background, socioeconomic status and other factors.

Unfortunately, many people face health inequities – or health disparities – that prevent them from attaining their full health potential. Because of these disparities, they may have differences in length of life, quality of life, rates or severity of disease and access to care.

How Is CentraState Helping?

At CentraState, we support the elimination of health disparities as a National Patient Safety Goal so that all Americans can achieve optimal health. We work to identify where health disparities exist, address these inequities and connect people to resources to achieve better health. Here are just some of the strategies we use.

We pinpoint areas of need in many ways. For example, our population health coordinators identify gaps in care access based on patient data and demographics using certified and confidential Epic electronic health record technology. We screen more than 12,000 adult inpatients each year for social factors that impact health equity – also called social driver of health – including access to food, transportation, medication, housing, utilities and personal safety. Likewise, our primary care providers screen patients to identify health inequities. 

Once social and clinical needs are identified, our health equity coordinators, social workers and clinicians connect patients to the specific resources they need for better well-being. Unite Us technology is integrated into the Epic electronic health record to seamlessly link hundreds of patients each year to community-based organizations that serve their needs, most commonly housing, transportation and food. Our population health social worker serves as a navigator to assist with and confirm these connections. In addition, our RN health coaches educate patients on health conditions and chronic disease management to help them prevent risks, complications and unnecessary hospitalizations. 

Additional advocacy strategies include participating in local, regional and national quality improvement activities focused on reducing health disparities. We also recruit diverse and bilingual team members, cultivate a culture that prioritizes health equity and train staff in cultural humility and other relevant topics aimed at eliminating health disparities. 

Beyond identifying patient needs within the hospital, our team members connect with people where they work and live to expand access to health resources for underserved populations. We use data from public health resources like City Health Dashboard and the CDC’s Social Vulnerability Index to help us target our outreach efforts. Outreach ranges from free screenings and chronic disease management coaching to mobile food pantries and community suppers. Since the pandemic, our population health team has provided countless protective vaccines for people in area prisons and migrant communities.

We’re proud to partner with community organizations and agencies to ensure that health-related social needs are managed and resolved. We broaden our impact in reducing health disparities by working with organizations such as Neighborhood Connections to Health, VNA Health Group, Ocean Monmouth Health Alliance, food pantries, faith-based organizations, local school systems, social service agencies and health departments. 

Health Equity Initiatives and Resources

CentraState Medical Center’s Health Equity initiatives include:

Adults in the U.S. have a 40% chance of developing type 2 diabetes during their lifetime, and risks of complications are greater in people of color. As a health equity priority, our team members offer screenings to identify those with prediabetes and provide education to reverse its course. Our evidence-based Diabetes Prevention Program is recognized by the CDC and is the only grant-funded program of its kind in New Jersey. In addition, we work to ensure that patients and community members with diabetes – especially those in geographic areas with high incidence rates – have access to comprehensive self-management education and the devices needed to successfully manage their condition.

CentraState physicians care for patients at the Freehold Family Health Center, a unique collaborative initiative with the VNA Health Group-VNACJ Community Health Center and Rutgers Robert Wood Johnson Medical School through our Family Medicine Residency Program. Located within walking distance from downtown Freehold, the center offers services designed to keep families healthy, with a special focus on underserved populations. With more than 15,000 patient visits each year, the center recently added dental services and will soon open a pharmacy to make care even more convenient and affordable.

Through a dedicated RN health coaching program in collaboration with the First Impressions Maternity Center, CentraState has taken proactive steps to ensure that pregnant women – including underserved populations – have free access to resources that educate, support and engage those with early signs of preeclampsia. This serious pregnancy complication is characterized by high blood pressure and protein in the urine. A key component of the program is the use of home blood pressure monitors, provided by CentraState through a grant partnership with TD Bank, to encourage regular monitoring. As a result, the program has successfully identified several women at risk for severe complications and ensured they received timely and appropriate care. 

Unmet health-related social needs can complicate access to treatment for substance use and mental health issues, posing a significant barrier to optimal health. CentraState has strengthened its commitment to providing and documenting mental health and substance use screenings and referrals to help patients find housing, food and transportation. Our participation in the Quality Improvement Program–New Jersey (QIP-NJ) demonstrates that CentraState is consistently ranked among the state’s top performers formeasures of performance such as depression and substance use screening and access to follow-up care within 30 days. 

Our analysis of health disparity data recently uncovered that Black individuals were returning to the CentraState Emergency Department at twice the expected rate. Through a generous grant from the Grunin Foundation, we are examining the impact of a home-based education and social care model to address this disparity. In this model, a nurse provides post-discharge education and coaching for individuals in their homes, ensuring medication compliance and access to follow-up care. In addition, a population health social worker facilitates connections to community-based support as needed. 

Community Resource Directory

Browse a comprehensive directory of local community resources and social programs available to support your overall health, such as accessing healthy food, medication assistance, transportation and housing resources and much more. To find community resources in your area based on your needs and preferences, search by zip code and category or keyword.

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