Your organization is working to reduce disjointed care among people who need both behavioral health and physical health treatment. Recently you hosted a site visit for the public at your organization’s Behavioral Health Home. Can you tell us about it? 

The Good Care Collaborative organized the event to recognize the work that we do at CarePlus, specifically to highlight our Behavioral Health Home model. We explained the evolution of our care integration model. The organization has been around since 1978 and has taken many approaches through the years. When we first started as Mid-Bergen Community Mental Health Center we would refer our patients to primary care doctors. But we found that often there was no communication between the outside providers and us. The lack of communication would have damaging effects: a patient’s blood sugar would spike, they would pass out, and they would go to the hospital, for instance. Or they might have an acute psychotic episode and, without proper follow up, would end up in the ER. This resulted in high rates of ER visits and hospitalizations.

How is your model different today?

Over the last decade our model has evolved tremendously. We are now a licensed ambulatory center, have an advance practice nurse on site full time and have a primary care practice embedded into our behavioral health care service. We have a nutritionist, a nurse case manager, and a diabetes educator. Surrounding that we have case managers who are trained to treat both body and mind. The integrated approach takes many factors into consideration, and produces much better outcomes.

What does that mean for patients?

Mental disorders are brain diseases. One of the things we’ve learned is that many of our patients experience the negative effects of medications, such as weight gain. We see patients with diabetes, hypertension, and smoking-related illnesses, such as COPD. With the integrated care model a patient can come to us and see a psychiatrist, get a blood test right on site, and then visit a primary care physician to review test results. Everything is coordinated.  We are making a difference, and the patients are taking a more active role in their treatment and wellness plan. We value the relationship between provider and patient, and emphasize the importance of compassionate care.

You have seen substantial declines in ER visits. Can you tell us about that?

The implementation of our care integration model reduced emergency room visits by 82 percent over a one-year period. We currently are measuring the data within our Behavioral Health Home. We have 130 patients enrolled in the program who have persistent mental illness as well as one or more co-morbid conditions and who also receive Medicaid. We have a strong focus on wellness and have built an on-site gym that people really enjoy. Among these patients we’ve seen a significant reduction in hypertension and we’ve helped most of our patients with diabetes get their disease under control. The participants have lost an average of nine pounds through these efforts. I have to say that smoking cessation remains a challenge, but the percentage of our patients who are involved in our efforts is higher than the national average.

What can we learn from your success?

Promoting care coordination and integrating behavioral and primary health care has a bang-for-the-buck value that needs to be talked about. We are improving outcomes by focusing on four pillars for success in this model: primary care, mental health care, substance abuse treatment, and access to social services. Our value proposition is better outcomes and reduced costs. We think the model has value beyond Medicaid patients and can help many other populations. That’s what we are working on now with our Health Management Solutions team.