A couple of years ago, “PD,” a Horizon member mired in a dangerous stew of physical and psychological health challenges, was overwhelmed. She couldn’t manage her clinical symptoms, and compounding matters, she was too intimidated by the complexity of the health care system to get the help she really needed. But thanks to an integrated, “whole-person” model of care that Horizon was piloting, she found a “quarterback” in whom she could entrust her care. Today, her life has been transformed and based on the progress of the program to date, her tomorrow is looking much brighter, too.

PD, who has agreed to share her story anonymously, experienced problems that were only growing worse and more complex over time. Her conditions were precisely those that met the criteria for a new Integrated System of Care (ISC) program, designed outside the coloring lines of traditional health care delivery, that Horizon began piloting in July of 2019 with CPC Behavioral Healthcare of Monmouth County.

“Patients often present a set of co-occurring conditions that multiple health care providers treat in an uncoordinated way or in too many cases, not effectively at all,” said Saraí Narváez, Director of Horizon’s ISC program. “This, in part, is due to the siloed way in which the health care system itself operates.”

Narváez explained the professionals at CPC connected PD to the supportive care and services she needed to manage the full breadth of her physical, behavioral, and social determinants of health (SDoH) needs. As her “quarterback,” CPC made sure PD made and kept appointments for psychiatric counseling, took prescribed medications to treat her illness, and was free from administrative obstacles to get the specialist care she needed for a chronic back and spine condition.

Success of an Integrated Approach: By the Numbers

In less than a year, PD’s improved mood, higher energy level and overall better health have put her on track to go back to work as a child care provider. With this concentrated level of intervention, members in this pilot, which focused on patients with serious mental illness and/or substance use disorder and a potential chronic health conditions intertwined, reported that they experienced:

• 100% reduction in hospital stays
• 71% reduction in ER visits
• 87% reduction in days of alcohol use
• 95% reduction in days of illegal drug use
• 38% improvement in quality of life

Growing to Reach More in Need

After the successful pilot with CPC, Horizon recruited additional similar partner organizations to replicate and stretch the program’s reach to Burlington, Camden, Mercer, Monmouth and Ocean Counties at the beginning of 2021.

Oaks Integrated Care of Cherry Hill serves as a lead and coordinating agency in this expansion. As one of four “quarterbacks” or “integrators” for at-risk patients in the region, Oaks screens and assesses patients for program eligibility, then works with them to develop personalized care plans to overcome unmanaged issues that lead to poor health outcomes. Oaks coordinates and integrates the care with its staff and community partners that deliver a broad range of services, from crisis intervention and acute outpatient care, to addressing food insecurity and homelessness.

 “Horizon and Oaks Integrated Care understand that treating the whole person is fundamental to helping individuals with complex challenges achieve and maintain better health,” said Michael D'Amico MSW, LCSW, Vice President of Oaks Integrated Care.

“Mental and physical care are interconnected. Research shows you can’t treat one effectively without the other. If I don’t have a place to live or means to get treatment, the treatment won’t be nearly as effective. People need strong supportive environments in which to recover and lead healthy and productive lives. It’s incumbent upon providers to do a better job of coordinating and collaborating to guide the patient through the system and treat different aspects of themselves,” he said.

According to research from the Cleveland Clinic, one-third of individuals with a serious medical condition also experience symptoms of depression. This same population is also at heightened risk of falling victim to a substance use disorder (SUD). The National Institute of Mental Health notes that about half of individuals who experience an SUD during their lives will also experience a co-occurring mental disorder and vice versa.

Narváez added: “Absent an intuitive approach to whole person care, patients too easily get shuffled in and out of ERs and inpatient settings and don’t get better,” she said.

The addition of Oaks and expansion to five counties marks a methodical step toward a state-wide expansion. Horizon is currently soliciting proposals from licensed and qualified integrated care operators to reach members in northern New Jersey, with the goal of reaching a state-wide presence by early next year.

“Making our health care system work better for those who depend on it requires us to reimagine how we deliver services. Based on what we have learned through the ISC experience, putting a ‘quarterback’ or ‘integrator’ at the center of a patient’s complex health care journey is a simple yet quantum leap in the quality of health care delivery,” Narváez said. “It also demonstrates how improving the quality of care can also lower the cost of care.”