The WFNJ SAI/BHI Care Coordination model successfully continued into its 17th year providing comprehensive assessments, referral to treatment, and care management of GA/TANF recipients whose substance use and/or mental health disorders were a barrier to their employability.
The men and women referred to the WFNJ SAI/BHI are in need of a variety of services, they are guided into treatment and their services are monitored across a continuum of care based on their changing needs. As a Work First-NJ initiative, clients are assisted with planning for discharge and employability along the way. Care coordination addresses potential gaps in meeting clients’ interrelated medical, social, environmental, educational, and financial needs in order to achieve sobriety, psychiatric stability, and self-sufficiency. A significant amount of time is spent advocating on behalf of clients for cash assistance from County Welfare Agencies, Medicaid coverage, housing, childcare, and other supports, while helping them to navigate multiple community systems; thereby, reducing fragmentation of care. Successful outcomes are met when clients are actively engaged in the entire process and in accordance with their immediate needs and preferences. Further, ongoing utilization review takes place with SUD and MH treatment providers to ensure appropriate delivery and collaboration of healthcare services.
The WNFJ SAI/BHI is located in all 21 New Jersey Counties with 57 licensed or certified Care Coordinators located in the County Boards of Social Services or One-Stop Career Centers. In fiscal year 2015, WFNJ SAI/BHI Care Coordinators conducted 8,920 assessments, 7,443 were assessed to need treatment, and of those assessed to need treatment 5,859 entered treatment (79%).
Since inception in July 1998, it was determined that many individuals had co-occurring substance use disorders (SUD) and mental health disorders (MH); therefore, treatment referrals must be tailored to meet the specific needs of each client. In fiscal year 2015, it was identified that 28% of clients referred were assessed and determined to have substance use disorders only (no mental health conditions or history), 22% were assessed and determined to have mental health disorders only (no substance abuse or history), and 50% were assessed to have co-occurring substance use and mental health disorders, with primary presenting diagnoses as either SUD or MH.
The WFNJ SAI/BHI provides comprehensive face-to-face assessments using an enhanced version of the Addiction Severity Index; this evaluation includes a Child Safety Evaluator and an Immediate Need Profile. Care Coordinators utilize the ASAM Criteria, 3rd Ed., and the DSM-5 when determining their diagnostic impression and most appropriate level of care placement. Data collection using these tools assists with identifying the needs of the population and improves client care with linkage efforts across all health domains. In fiscal year 2015, in addition to substance use and/or mental health disorders, it was identified that 60% of clients self-disclosed at the time of assessment they had been diagnosed with chronic medical conditions. The Care Coordinators will then ensure the clients are obtaining necessary medical follow up or will refer to medical care for those in need of health services.
Trauma, abuse, and domestic violence plague the population we serve. Many WFNJ SAI/BHI clients have a history of trauma or current experiences of harmful relationships. At the time of assessment, 46% disclosed current or historical emotional abuse, 41% had experiences of physical abuse, 30% disclosed sexual abuse, and 18% all three. The Care Coordinators address these sensitive areas with the clients and refer for services to ensure their safety. Many men and women with a history of trauma have never had counseling and may not be ready for treatment. The Care Coordinators attempt to connect them to services or provide them with linkages for when they are ready.
The extensive data collection within our health information system not only permits us to collect diverse information on the needs of our population but it provides the ability to generate over 90 reports on the data collected. This data is available to the State any time information is requested regarding client care, client flow, demographics, and quality assurance to illustrate performance targets and outcome data.
In fiscal year 2015, 20% of clients were placed in a residential treatment program; 6% detoxification, 6% short-term residential, 4% halfway house, 4% therapeutic community. The majority of clients were placed in an outpatient setting; 37% outpatient, 27% intensive outpatient, partial care 10%, and medication-assisted therapy 6%.
The WFNJ SAI/BHI model offers a single-point of care coordination ensuring the most efficient course of action centered on client needs. This model also recognizes the strengths of the clients to achieve optimal outcomes, move clients seamlessly along the continuum of care, and emphasizes recovery, wellness, and self-sufficiency as the guiding values. Through the steadfast efforts of the WFNJ SAI/BHI, we have developed an accountable behavioral health system that has significantly assisted with attaining the State’s goals for quality care, accessibility of care, eliminating gaps in service, and cost effectiveness.