CEO Focus

Addressing Social Determinants of Health

Saint Peter’s puts Catholic mission into action every day.

By Topic: Leadership Leadership Development Social Determinants


Saint Peter’s Healthcare System is one of New Jersey’s few remaining independent, single-hospital health systems with a long history of humbly serving humanity, preserving the dignity of each life and providing safe, quality care to all. As a Catholic institution serving central New Jersey for over 100 years, addressing social determinants of health and healthcare disparities among the most vulnerable in the community is a top priority. We have made it our mission to proactively remediate key issues negatively impacting overall health and well-being, including food insecurity, housing instability, transportation access, exposure to domestic violence and substance use. 

One of the health system’s major initiatives to enhance access to patient care is Saint Peter’s Family Health Center, located just minutes from the main hospital. The Family Health Center is one of the few of its kind in New Jersey and provides patients with access to comprehensive primary and specialty care services. With 60,000 adult, pediatric and women’s health visits annually, upward of 90% of the center’s patients are covered by the Affordable Care Act, Medicaid, Medicaid Managed Care or the New Jersey Hospital Care Payment Assistance Program (Charity Care).

Intake surveys conducted by staff help identify specific social determinants of health that are more likely to put a patient at greater risk for potential health crises that could result in an ED visit or hospital admission. Staff then informs patients about the benefits programs for which they may be eligible, including assistance with food, childcare, paying bills, tax credits and more. 

Saint Peter’s has invested $12 million into a modernization project of the Family Health Center to expand the organization’s reach to 100,000 annual visits. Integrated in all new and existing services is a heightened focus on identifying social determinants impacting health and enhanced efforts to work with community leaders to address these issues. The project will increase and upgrade health exam rooms to 75, from 49; add new laboratory services; expand behavioral health services; create a large physical therapy space; and introduce an on-site food market. The expansion project is scheduled for completion this year. 

Saint Peter’s focus on food insecurity includes collaborating with local farmers markets and providing vouchers to patients so they can obtain more nutritious foods. The health system has also partnered with a local food pantry to host food truck events, distributing hundreds of meals to patients and the community.

Lack of transportation is a major impediment to patients seeking care at the Family Health Center. Ridesharing services provide transportation to the center, as well as to the hospital and other off-site locations. Saint Peter’s recently secured a grant to fund transportation costs to and from the center and to support a ride coordinator: someone who helps identify patients with a transportation risk factor and oversees ride request intakes. Grant initiatives will also include the use of translated outreach materials to accommodate diverse patient populations and staff training to better recognize and address social determinants of health factors, connecting patients to resources needed for best health outcomes. 

The Family Health Center offers primary and specialty care to adults and children, from newborns to young adults. It also provides obstetrical care to women—from prenatal care to intrapartum and postpartum care—as well as gynecological services. 

The health system’s Pediatric Health Center, a service of The Children’s Hospital at Saint Peter’s University Hospital, administers over 26,000 immunizations, including COVID-19 vaccines. The center is a leader in Vaccines for Children, a federally funded program that provides vaccines at no cost to children who otherwise might not be vaccinated due to an inability to pay.

Saint Peter’s Family Health Center also houses two unique pediatric specialty programs. The For KEEPS program, which stands for Kids Embraced and Empowered through Psychological Services, is a short-term, acute, partial-hospitalization unit offering high-quality mental health diagnoses and intensive treatment to children, ages 5 to 17, who are experiencing emotional and behavioral difficulties. 

Services include individual, group and family therapy; academic instruction in collaboration with the child’s school district; and medication management. The program, licensed by the New Jersey Department of Health and Senior Services, has been cited as “a model for children’s partial hospital programs statewide.”

As one of the state’s four child protection centers, the Dorothy B. Hersh Child Protection Center is a state-designated child protection center, providing crisis intervention, child abuse assessments and referrals to community resources throughout eight counties. The CPC has established working relationships with local offices of the Division of Child Protection and Permanency, prosecutors’ offices, and many local mental health providers, pediatricians, schools and police departments within the seven counties of the state’s central region. We are proud of the fact that our center remained open throughout the pandemic to provide care and resources to children and families in crisis, not only in our communities but also throughout the state.

At Saint Peter’s, we also are working to reverse the alarming trend of opioid use in Middlesex County through our Opioid Task Force, which includes ED physicians, nurses and pharmacists, law enforcement, addiction recovery specialists, and social agencies dedicated to educating and engaging the community. In the ED, Saint Peter’s clinical team connects patients in crisis—many of whom are experiencing an overdose—with recovery coaches, whose goal it is to help these individuals enter recovery.

Saint Peter’s also addresses the lack of housing or adequate housing through a multisector coalition of organizations and community members known as the New Brunswick Healthy Housing Collaborative. The Healthy Homes Project works to ensure all New Brunswick residents live in safe homes that facilitate healthy living. The team focuses on improving health outcomes by mitigating housing issues and identifying those neighborhoods with the greatest health and social disparities.

Dilapidated structures, poor heating, rusty plumbing, mold, dust and lead paint are all associated with adverse health conditions like respiratory infections, asthma and lead poisoning. The collaborative uses a referral system to direct community members toward available resources with the common goal of promoting personal health and healthy living environments.

The hospital’s community health services mobile health van is another way of bringing the hospital’s extraordinary care services to wherever community need exists. Making healthcare convenient and accessible is critical to reducing the impacts of healthcare disparities, and the van travels to sites where services may be limited, including schools, retirement communities, daycare centers, homeless shelters, senior centers, public housing complexes, shopping centers, churches and corporations. Once on location, the van offers vaccinations, preventive screenings and assessments for blood pressure, cholesterol, blood sugar, vision, hearing and stroke.

As part of this outreach, Saint Peter’s awarded 13 one-time grants to local organizations last year in support of their efforts to address social determinants of health. The grants, totaling $500,000, will help improve the lives of those affected by food insecurity, mental health or lack of education and resources. The recipients included support for student scholarships at Catholic schools, food pantry ministries, mental health support for youth and young adults, and support for minority businesses and several faith-based organizations. The diversity of the organizations supported reflects Saint Peter’s mission to serve individuals in the New Brunswick and greater Middlesex County region regardless of religious, ethnic or socioeconomic background. 
Saint Peter’s Healthcare System is open to all in the community, committed to serving the most vulnerable in a discrete and compassionate way, along with its focus on reducing the impact of social determinants on individual health and well-being. Saint Peter’s is putting its Catholic mission into action on an everyday basis, providing skilled, compassionate care along with education and outreach to promote proactive, preventive healthcare measures to all. 

Leslie D. Hirsch, FACHE, is president and CEO, Saint Peter’s Healthcare System, New Brunswick, N.J. (

Saint Peter’s by the Numbers

Location: New Brunswick (Pop.: 55,000), N.J., in Middlesex County (Pop.: 863,000). 
Demographics: 42% white, 26% Asian, 22% Hispanic and 10% Black, according to the U.S. Census Bureau. One-third live below the federal poverty level.

Moving the Needle

Below are some of the results St. Peter’s is experiencing: 

  • Nearly 300 patients of the Family Health Center have been identified as being food insecure through Protocols for Responding to and Assessing Patients’ Assets, Risks and Experiences, a national standardized tool designed to equip health systems and their community partners to better understand and act on individuals’ social drivers of health.
  • Approximately 300 rides per month are being offered to Family Health Center patients who have been screened and identified for the need based on income and availability of transportation to address accessibility and reduce the center’s no-show rate.
  • Over 2,300 patients at the Family Health Center have been screened. Top issues identified are lack of social support, low income and issues related to employment.