Integrating Behavioral Health into Primary Care in Six New Jersey Clinics: AtlantiCare Special Care Center

The AtlantiCare Special Care Center (SCC) is an ambulatory care practice that cares for low-income adult patients with chronic medical conditions such as heart failure, diabetes, asthma, chronic obstructive pulmonary disease, and cardiovascular disease. The center has two additional practices under its umbrella—an outpatient primary care for the hospital Medicaid waiver program and a primary care practice for behavioral health patients. The total active patient population is 2,400 with an estimated 25% needing behavioral health consultation.

This project supports the implementation of Cherokee Health System’s model of integrated care into AtlantiCare’s SCC. First, Cherokee trains selected leadership staff in the model at a 2-day Integrated Training Academy, held at Cherokee’s Knoxville, Tennessee, location. Cherokee then works closely with AtlantiCare to recruit and hire behavioral health consultants (BHCs), who are embedded in the clinic’s primary care teams. The BHCs also are trained in the Cherokee model. Once the project is staffed, Cherokee works with the clinic on an ongoing basis to operationalize and sustain the integrated care model. This involves evaluating and adapting clinical flow practices and clinical spaces to facilitate the integration of behavioral health into primary care services, providing onsite training and periodic clinical coaching calls to improve the quality and quantity of brief behavioral health interventions that BHCs provide, and instituting practices to facilitate effective communication between the BHCs and primary care teams.

The project also incorporates several strategies that foster AtlantiCare’s commitment to this initiative and enhance the likelihood of long-term sustainability. Cherokee holds periodic calls with AtlantiCare’s leadership team that provide an opportunity for the team to create a vision for integrated care, discuss communication and patient outreach efforts, and consider quality improvement and financial sustainability issues. Cherokee also trains clinic staff in billing procedures that maximize reimbursement for delivering integrated care. In addition, Cherokee works with staff to track and document the process of implementing the integrated care model and to measure the impact of this practice transformation effort on patient outcomes and clinic operations.

AtlantiCare is one of six primary care sites participating in this care integration initiative. To build cohesion across the sites, Cherokee holds periodic conference calls with all the sites. These gives the sites an opportunity to provide peer support, learn from each other’s experiences, and share success and challenges. The other sites participating in the initiative are:

Eric B. Chandler Health Center

Hackensack Meridian Family Health Center

Kennedy Family Health Services

Metropolitan Family Health Network

Visiting Nurse Association of Central Jersey

Learn more:  

AtlantiCare Foundation