Integrating Care to Reduce Health Disparities in a Medical Home II

The Henry J. Austin Health Center (HJA) is a Federally Qualified Health Center and the largest non-hospital-based ambulatory care provider in Trenton. Its goal is to provide patient-centered, comprehensive, accessible, and high-quality primary care, mental health, and substance use treatment services to uninsured and medically underserved communities in the greater Trenton area. HJA provides care to approximately 19,000 individuals at four locations.

This project continues previous Nicholson support for efforts to deliver integrated primary care and behavioral health (BH) services through an approach that uses an evidence-based integrated BH model developed by Cherokee Health Systems. The model embeds a Behavioral Health Consultant (BHC) within a primary care team to provide brief interventions to help patients address their behavioral health issues. The model is used in conjunction with web-based cognitive behavioral therapies developed by Cobalt Therapeutics.

The goal of this project is to improve the quality of integrated care provided to HJA patients and increase the number of patients who receive this care, thereby helping HJA achieve financial sustainability for their BH integration services. To maximize the effectiveness of the BH model, HJA has added two components to their approach to deliver integrated care. At one HJA location, the project is conducting a pilot test of a Patient Activation Measure tool, which will be used by BHCs. The tool assesses patients’ ability and capacity to participate in their own health care, and it will help the BHCs structure patient interactions, develop appropriate interventions, and improve the quality of their encounters. The second component is the addition of a community health worker to the primary care team to help BHCs track, and report back on, the progress of patients who are referred to off-site BH services.

Learn more about the Henry J. Austin Health Center

Media Coverage

3-minute case study: Integrating behavioral health

Other Related Grants

Integrating Care to Reduce Health Disparities in a Medical Home

Onsite Clinical Training and Supervision of Behavioral Health Consultants

Computerized Cognitive Behavioral Therapy Programs and Behavioral Health Screening Tools