Integrating Behavioral Health into Primary Care in Six New Jersey Clinics: Visiting Nurse Association of Central Jersey

Visiting Nurse Association of Central Jersey
Project Period: 
Funding Amount:
Program Area:
Primary Care
Geographic Area: 
Monmouth County

The Visiting Nurse Association of Central Jersey (VNACJ) Community Health Center is a Federally Qualified Health Center that provides comprehensive primary and preventive healthcare and wellness services to low-income New Jersey residents of all ages at four locations in Monmouth County.

This project supports the implementation of Cherokee Health System’s model of integrated care into VNACJ’s services at their Asbury Park location. 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 VNACJ 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 VNACJ’s commitment to this initiative and enhance the likelihood of long-term sustainability. Cherokee holds periodic calls with VNACJ’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.

VNACJ 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:

AtlantiCare Special Care Center

Eric B. Chandler Health Center

Hackensack Meridian Family Health Center

Kennedy Family Health Services

Metropolitan Family Health Network

Learn more:  

Visiting Nurse Association of Central Jersey