Early Efforts Paved the Way for Agency’s Health Home Pursuit

The community behavioral health organization Care Plus New Jersey certainly has come a long way since the days when it would refer patients to primary care clinics and would hope to receive some feedback, or that an appointment actually would be fulfilled at all. Today, the organization takes matters of patients’ physical wellness into its own hands, with features ranging from on-site medical staff to the presence of facility gym equipment for clients.

The northern New Jersey organization, which operates 22 service locations and treats around 20,000 individuals a year, received confirmation of its work in promoting whole health and wellness when it learned this month that it had become the state’s first organization to receive provisional certification as a behavioral health home. While Care-Plus will have to complete additional accreditation requirements to receive the official behavioral health home designation, its emergence ahead of other organizations in the process reflects progress in integrated care that it has achieved for many years.

“We embrace wellness as part of our organizational culture,” CarePlus President and CEO Joseph Masciandaro told MHW. Citing some examples, “Our nurses go around measuring our clients’ oxygen capacity and showing them the results — it has a powerful effect,” he said. “We have a nutritionist as a consultant, a diabetes educator as a consultant.”

Stages of development

Masciandaro describes his 37-year-old organization’s experience with integrated care as evolving over numerous stages. In its earliest years, it would refer its mental health patients to local clinics for their medical needs, but it rarely would hear anything about what patients’ doctors were ordering or prescribing, Masciandaro said.

In the late 1980s, CarePlus brought a physician in-house, but patients still had to use clinics elsewhere when their needs didn’t coincide with the physician’s hours. Low reimbursement rates for the medical services ultimately jettisoned the idea altogether.

A pivotal decision occurred at the next stage in the early 1990s, when CarePlus opted for a modified version of a recommendation from state officials to use more psychiatric advanced practice nurses, deciding instead to hire a general medical nurse. “We gained a real appreciation of the value of participation from physical care professionals on a multidisciplinary team,” said Masciandaro.

In the stage prior to its pursuit of the behavioral health home certification, CarePlus became one of the original grantees in the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) grant program for primary care and behavioral health integration. “This allowed us to bring staff in-house,” said Masciandaro.

The process was not simple: It would take CarePlus around 18 months to receive a required certification from the state as a medical facility. The organization even would have to take what appears to be a counterintuitive step: to demonstrate that it had separate physical space for primary care and behavioral health functions, even though what it was trying to achieve was more integrated care.

Last October, CarePlus saw the completion of its four-year SAMHSA grant cycle, and now attention has turned to the behavioral health home concept. It is indeed just that, Masciandaro says — a concept rather than a place. The idea is to provide centralized and coordinated care for individuals with chronic co-occurring disorders, including mental health and substance use disorders.

Masciandaro believes the concept ultimately will allow CarePlus to serve more individuals beyond those who already tend to visit a behavioral health service site frequently.

The organization already has accreditation as a behavioral health agency from The Joint Commission, but now will also pursue accreditation under the accrediting body’s behavioral health home standards over the next six months, a requirement of the state’s process. CarePlus says it already has met another of the state’s requirements for a behavioral health home: to have maintained an embedded medical practice, which the SAMHSA grant enabled the organization to achieve.

Masciandaro appreciates that his organization has moved ahead of some others in its planning. “Most of the agencies have the elements of care coordination, but most still really have to do a lot of the developmental work,” he said.

Process unfolding

The funding picture for this next iteration of integrated care remains somewhat uncertain. Masciandaro said much of his organization’s reimbursement still occurs on a fee-for-service basis, but what is being discussed for the future are per-member per-month rates resembling a capitated system, with varying dollar values depending on whether a client is in an engagement, treatment or maintenance phase of service.

Making the transition to a wellness and recovery mind-set has required a great deal of internal examination within the organization, said Masciandaro. After all, it is difficult to say one is promoting wellness when some clients are taking psychotropic medications that result in substantial weight gain, or when some staff members neglect proper self-care.

“We seek to achieve no boundaries between clients and staff — everyone has the same goals,” Masciandaro said.

Also, for its efforts to work, clients must choose to participate, and have an interest in stress reduction, nutrition and exercise, he said. “None of this is going to work if we see this as ‘performing this’ on someone,” he said.

While a great deal of effort will go into the behavioral health home certification, Masciandaro does not see this as a last step. “I think this is another stage,” he said. While it is difficult to project too far into the future, he believes that small organizations providing only mental health services will have a hard time maintaining operations in the long term, as the front door for services begins to resemble more closely a primary care operation.