Helping Local Providers Better Integrate Physical, Behavioral Care

Nicholson Foundation seeks to benefit low-income patients at six community clinics

poor people waiting room
New Jersey officials are considering significant structural changes to the division that operates the state’s mental health and addiction services in an effort to better integrate behavioral and physical healthcare, especially for vulnerable, low-income patients.

Now, a Garden State healthcare foundation has provided $1.35 million to help a half-dozen community health clinics pursue similar goals on a more local level, a push to improve care for as many as 42,000 patients in five counties: Atlantic, Camden, Hudson, Monmouth, and Middlesex.

The Newark-based Nicholson Foundation announced last week it will give each clinic a $225,000 grant to train staff in a national model for effective integrated care and hire physicians, nurse practitioners, behavioral health professionals, and others who can help coordinate patient care. The work will be based on programs developed by Cherokee Health Systems, a Tennessee-based pioneer in integrated care that has worked for decades to spread the model to other areas.

“Integrated, team-based care will greatly improve overall healthcare for vulnerable patients in New Jersey,” said Barbara Kang, Nicholson’s senior healthcare program officer. “Although behavioral health has traditionally been separated from the physical healthcare delivery system, a solid research and clinical consensus has existed for decades that integrated clinics that treat the ‘whole person’ produce better outcomes for individuals while lowering total costs to the system.”

Making a priority of integrated care

Nicholson, which is focused on improving care for low-income communities, has prioritized integrated care in recent years. The foundation funded pilot projects in Trenton and Lakewood that helped shape the latest round of grants; the Lakewood project showed real promise in reducing depression in many patients. It also backed a Seton Hall report by Prof. John Jacobi and his colleagues, published in March 2016, that identified New Jersey’s existing operational and regulatory barriers to better coordinated healthcare.

Jacobi’s report — and the meetings he has held with state officials since its release — also contributed to a plan developed by Gov. Chris Christie, and released to the Legislature in late June, to shift addiction and mental health services from their current home in the Department of Human Services to the Department of Health, which licenses and regulates medical care. Christie’s proposal did trigger controversy and spark concerns from some advocates and lawmakers who said a sudden shift would actually endanger behavioral treatment for vulnerable residents.

Better integrated care helps address several persistent concerns for healthcare experts and has become a priority for reformers. The issue was one of five areas of focus identified in the Medicaid 2.0 reform plan drafted by the New Jersey Health Care Quality Institute, also with funding from Nicholson.

Lack of care

Experts agree there is now a lack of community-based mental healthcare in the Garden State and primary-care providers are generally trained in physical care and unprepared to diagnose or treat behavioral problems. As a result, scores of patients with mild-to-moderate mental health issues don’t get diagnosed or properly treated, which only exacerbates their condition.

According to the Mental Health Association in New Jersey, the average wait for outpatient mental healthcare is three to six months in most counties. A study from the New Jersey Hospital Association found that in recent years nearly half the growth in emergency room use has been a result of patients in a psychiatric or drug crisis, situations most facilities are not well equipped to properly address.

By training primary-care providers to better identify the signs of mental illness and stocking their offices with behavioral health experts who can help, patients with mild-to-moderate psychiatric issues can be treated at their regular doctors’ office, before things get more severe, Nicholson said. That enables the existing behavioral health providers in the community to focus more time on patients with severe illness.

Nicholson selected the following organizations, all of which serve large numbers of Medicaid and uninsured patients: Eric B. Chandler Health Center in New Brunswick; Visiting Nurse Association of Central Jersey’s Community Health Center in Asbury Park; AtlantiCare in Atlantic City; Metropolitan Family Health Network in Jersey City; Kennedy Family Health Services in Somerdale; and Hackensack Meridian Family Health Center in Neptune.

Dr. Kristine McCoy, executive director of the VNACJ Community Health Center, thanked the Nicholson Foundation for helping them to continue to build their expertise in integrated care and expand behavioral-care services. The VNACJ partners with the VNA Health Group, the state’s largest Visiting Nurse Association; the VNAHG merged with its counterpart in Ohio earlier this year in what may be the first such partnership nationwide, in part to help the organization pursue new techniques and best practices that can help improve care delivery.

“The VNACJ Community Health Center is committed to transforming primary-care practice by adopting new, innovative models of care that improve the health and wellbeing of the families we serve,” McCoy said. “What is particularly special about the Cherokee model is the recognition of the close link between physical and psychological well being, where problems with one can trigger problems with the other. For example heart disease and depression are often closely linked.”

The Cherokee system, which started in Knoxville, now operates two dozen facilities in 13 Tennessee counties. As a Federally Qualified Health Center, or FQHC, Cherokee treats physical needs, but providers have been trained to also ask patients about their sleep cycle, mood, energy level, and ways of dealing with stress. If they detect a need for mental health or addiction services, other professionals are onsite to help address those aspects of the patient’s care.

Cherokee also provides dental services, operates a pharmacy, and coordinates care with outside providers; it can also arrange for transportation and connect patients with other social services. It operates a training academy for professionals from other states six times a year and hosts a post-doctoral program for physicians interested in integrated care.

“Through an integrated care approach, patients not only receive the highest-quality medical care for common conditions like diabetes and hypertension, but they also benefit from having real-time, immediate access within primary care for common behavioral issues such as stress, depression, or substance misuse,” said Joel Hornberger, Cherokee’s chief strategy officer. “Clinics and practices will be able to address the full spectrum of needs a patient presents with.”