Integrated Care Primary Mental Health

Salerno Medical Associates (SMA) has served East Orange and Newark, New Jersey for more than 50 years, providing comprehensive health care services to these communities. Instituting a population-based approach to care, SMA subscribes to the Institute for Healthcare Improvement (IHI) Triple Aim which promotes a framework to optimize health system performance by improving patient experience and the health of populations, while reducing the per capita cost of health care.

Before population health was a buzzword, SMA was already practicing this approach to health care delivery. Salerno Medical recognized that as risk factors differed from one population to the next, they must be identified and addressed strategically, to achieve desired health outcomes. The population health approach also ensures that outcomes are well distributed within the group, thereby optimizing health care delivery. Over the years, SMA has been on the frontline serving segments of underserved, inner-city communities, making comprehensive health care services accessible and treating the whole person in the process.

Today, Salerno Medical Associates brings population health to mental health services delivery in New Jersey, through CHOP, Community Healthcare Outreach Program. This innovative approach takes fully-integrated primary care services into the behavioral health facility, providing holistic health care for those with mental illness. It is a bidirectional approach to delivering mental health services where primary care is integrated into behavioral facilities and behavioral health is integrated into primary care facilities. The latter has been the practice supported across the country but does not necessarily result in improved health outcomes for individuals with mental illness. The National Association of State Mental Health Program Directors (NASMHPD) reports that people with mental illness die, on average, 25 years earlier than the general population, and highlights the importance of addressing chronic medical conditions in tandem with mental illness. Studies indicate however that, “…in spite of significant efforts to introduce integrated behavioral care during the past decade, the gap in life expectancy has not significantly changed.” (Brown et al., 2018

Why a population health approach to providing health care those with mental illness? It goes back to the risk factors peculiar to that population. Mental illness impacts physical health, affecting life expectancy, dramatically. The National Association of State Mental Health Program Directors (NASMHPD) reports that three (3) out of every five (5) persons with serious mental illnesses die due to a preventable health condition that is not directly related to their mental health condition but instead to its effect on their overall health and life circumstances. Mental illness increases the risk of several factors known to decrease life expectancy including chronic health conditions, infectious disease, poor self-care, poverty and suicide.

Individuals experiencing mental illness, for example, are at a higher risk than the rest of the population for developing diabetes and cardiovascular disease. Obesity is often a side effect of medications used, or hormone imbalances associated with the disease. Infectious disease such as hepatitis, HIV and tuberculosis are also prevalent.

Some self-medicate as a way of dealing with their condition, with the potential for developing substance use disorder and its challenges. For many, their condition makes it difficult to find or maintain stable employment leading to poverty, homelessness, and troubling encounters with the criminal justice system. Research shows that offenders with mental illness and substance use disorder recidivate at a higher rate than undifferentiated offenders.

Additionally, persons with serious mental illness, such as schizophrenia and bipolar disorder, tend to have higher recidivism rates than those with other psychiatric disorders. (Zgoba et al., 2020) And, although the risk of suicide differs depending on the mental illness, some mental illnesses such as depression, schizophrenia, and alcoholism, present higher risks of suicide. A more collaborative, holistic, integrated approach to care is required to better serve individuals with mental illness.

Integrated care is care provided by “…a practice team of primary care and mental health clinicians, working together with patients and families … [that] may address mental health and substance use conditions, health behaviors (including their contribution to chronic medical illnesses), the life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.” (Brown et al., 2021) CHOP is, an integrated model of health care delivery, which accounts for the risk factors experienced by those with mental illness, as it brings quality service, expertise, procedures, and collaboration through a well-coordinated, interdisciplinary medical team approach into the behavioral care setting. CHOP is the primary care arm of the practice team, providing “early, on-site treatment intervention of controllable and curable diseases like diabetes, cholesterol, high blood pressure, and cancer screenings…” saving patients from unnecessary disease and illness, and the health care system from unnecessary and costly hospital visits. (Salerno Medical Associates, n.d.) At present, Salerno Medical Associates collaborates with the Mental Health Association of Morris and Essex County to provide comprehensive primary care services to their clients. This innovative collaboration is not without its challenges as the current health care system does not provide for the seamless integration of these services.

COVID-19 and Mental Health

Preliminary and anecdotal analysis show that the COVID-19 pandemic has taken a toll on the mental health of all demographics, from children to the elderly, and high- to low-income earners; all have experienced a decline in mental health, especially among already vulnerable communities. Mental Health America (MHA) MHA reports that through September 2020, over 6 million people used their online tool to screen and obtain mental health support and that since March 2020, “mental health conditions and distress—with the number and rate of individuals scoring “moderate” to “severe” for depression and anxiety increasing over that period. (MHA, 2021).

Analysis conducted to identify those counties across the country, “most vulnerable to the negative consequences of COVID-19 and poor public health” reveals thirteen cities especially vulnerable because of a large proportion of residents vulnerable to the effects of COVID-19 and at risk for poor mental health, and which lack the local mental health care capacity to weather the crisis were identified. Alarmingly, among these are three New Jersey municipalities—Camden, Passaic, and Trenton.

City Proportion of residents living in highly COVID-vulnerable neighborhoods with high rates of poor mental health
Camden, NJ 84%
Reading, PA 78%
Detroit, MI 77%
Springdale, AR 65%
Passaic, NJ 62%
Allentown, PA 61%
Rochester, NY 60%
New Bedford, MA 54%
Albany, GA 54%
Buffalo, NY 54%
San Bernardino, CA 51%
San Bernardino, CA 51
Trenton, NJ 50%

Figure 1: Thirteen U.S. Cities Most Impacted by COVID-19 and Mental Health Source: The COVID Mental Health Crisis in America’s Most Vulnerable Communities (Surgo Foundation and Mental Health America, 2020)

The demographics of Camden, Passaic, and Trenton are repeated throughout New Jersey. A coordinated, comprehensive, urgent state-wide response is required, as the effects of mental illness are not limited to the individual.

NAMI, the National Alliance on Mental Illness, the “nation’s largest grassroots mental health organization dedicated to building better lives for the millions of Americans affected by mental illness,” reports that, “At least 8.4 million people in the U.S. provide care to an adult with a mental or emotional health issue, and that “Caregivers of adults with mental or emotional health issues spend an average of 32 hours per week providing unpaid care.” (NAMI, 2021) There is an economic as well as an emotional toll on the families of people with mental illness. Further, the effects do not end there but flow into the community.

Mental health illness exacts a high cost on the individual, the family, and the community, influencing outcomes in seemingly unrelated areas. If ever a strategic response were required, the time is now

Integrated Care in Action: Salerno Medical Associates

Changing realities require innovative responses and Salerno Medical Associates is taking integrated care beyond simply ensuring that primary and mental health services are provided simultaneously, to creating structures that will optimize health outcomes among those with mental illness.

Under CHOP home visits to chronically ill homebound patients are made by an advanced practice nurse and medical assistant. SMA averages 500 visits every six (6) months, with many patients on a regular monthly schedule or more frequently, if needed. Care is provided to patients where they are located, and when needed. This approach to care has been extended to include those with mental illness and is seen to be critical to success when caring for those with mental illness, especially those who come from a disadvantaged community.

Socioeconomic challenges further complicate health care for those with mental illness who also live in poverty. The reality is that our health care system is difficult to navigate for most. A visit to a primary care provider can often yield 4-5 referrals for testing or specialist care. One has to call to schedule appointments, hope that the health insurance carrier approves coverage before the appointment, show up for the appointment, and return to the primary care provider to review the results. For those with mental illness, this process is close to impossible to complete on their own. Mental illness adds layers of frustration to an already frustrating process. For those in the Newark/East Orange area, there are other obstacles to navigate. Specialists, for example, are often located outside of the area, requiring patients to step out of the familiarity of their community. Access to transportation often becomes a barrier to accessing care.

In this scenario, a primary function of CHOP is to support clients in navigating the health care system, successfully. Through a team-based approach, a patient navigator assigned to each team makes specialist/ clinic appointments, ensures patients keep those appointments and arranges transportation for patients to and from appointments. A team member calls patients on the day of the appointment to ensure they take the transportation to and from the appointment.

Follow-up and ongoing communication are also focal points of the CHOP program. As Salerno Medical Associates holds medical clinics two or three days per week onsite at the facilities where these populations congregate or reside, they can be in constant contact with clients and administrators to ensure patient services are provided and follow-up takes place.

Providing medical services to those with mental illness cannot be a passive endeavor. Services must be made available onsite and the approach must be aggressive. Health care for the mentally ill must be integrated; it must also be innovative to meet patients/clients were they are in their medical as well as socioeconomic states. When serving the poor, mentally ill and disadvantaged, Salerno Medical Associates sees firsthand that providing medical care within an integrated system is only the first step. Wrap-around service delivery through a collaborative team-based approach is essential to successfully serve those living with mental illness and thereby optimize the health outcomes of this population.

Through CHOP, Salerno Medical Associates is pioneering this innovative holistic model of health care for those with mental illness.

Systemic Changes to Support Integrated Care

To achieve successful integration and the optimal delivery of complementary primary care and behavioral care, changes are necessary. Interprofessional teams must be introduced, workflows adjusted, and billing and reimbursement policies and practices revised. As stated by the Mental Health Association of New Jersey (2018), “Systemic changes are needed to allow for the integration between mental health and addiction treatment along with physical health care in behavioral health care settings.” Barriers to sustainable integrated care must be removed, and incentives to support and encourage integrated care introduced. Some of these barriers to integration include how primary care and behavioral health services are billed. Reimbursement rates for services provided must be revised. Comparable reimbursement that recognizes and supports the cost of doing business and providing services must be introduced. Advocacy leading to a change in policy and practice to support integrated care is long overdue if mental illness is to be confronted, successfully.

About the Author & Acknowledgements

Authored by Denise L. Peroune, Ph.D. in collaboration with the Salerno Medical Associates team. Dr. Peroune has more than 25 years of combined experience in marketing and public health administration. She is a professor of marketing and business management at Monroe College, NY, and former chief operating officer of the City of Newark, Mary Eliza Mahoney Health Center, a Federally Qualified Health Center (FQHC) which serves Newark’s most underserved and underrepresented communities, including the homeless, uninsured and undocumented. Dr. Peroune also serves as a consultant grant specialist to the City of Newark Department of Health and Community Wellness.

Special thanks to Mary Ellen Roberts, D.N.P., R.N., A.P.N.C., FNAP, FAANP, FAAN, who provided the real-life case analyses. Dr. Roberts is certified as an Adult Nurse Practitioner and Acute Care Nurse Practitioner. Her professional interests are in the primary care of Adult Cardiovascular patients. Dr. Roberts maintains a practice with the Urban Health Initiative Program serving vulnerable populations in the greater Newark New Jersey area.


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  • The Mental Health Association of Essex and Morris, Inc. (2019). Strategic Plan. Zgoba, K., Reeves, R., Tamburello, A., & Debilio, L. (2020) Criminal recidivism in inmates with mental illness and substance use disorders. American Academy of Psychiatry and the Law. 48 2

Case Studies of Selected (SMA) Community Healthcare Outreach Program Clients

Improved Outcomes Through Integrated Care: The Salerno Medical Associates-MHA Experience.

The following cases and the positive outcomes experienced by clients are representative of the integrated approach to care followed by Salerno Medical Associates (SMA) and Mental Health Association (MHA).

Case Study 1

BD, a 60-year-old African-American female diagnosed with schizophrenia has been non-compliant with her medical care. At her first visit to Salerno Medical Associates Primary Care Clinic, after intake by the medical assistant to include vital signs, weight, height, BMI, and medical history, further evaluation by the nurse practitioner revealed a medical history of hypertension, chronic kidney disease and schizophrenia.

A care plan was crafted and BD has been seen in the clinic every 2 months when compliant. On one routine visit where BD had noticeable weight loss, a physical exam revealed a large lump in her right breast. Through SMAs extensive referral network, a series of tests were ordered and administered; BD was diagnosed with a malignant tumor.

After much discussion between the nurse practitioner and BDs MHA care team, BD was referred to a breast surgeon. She is now cancer free. BD rarely misses an appointment at the SMA Primary Care clinic. She has gained some weight and is more comfortable discussing her health needs with her care team, having had firsthand experience of an integrated approach to care.

Case Study 2

DJ is a 58-year-old African-American male diagnosed with schizoid-affective disorder. His first visit to SMA Primary Care Clinic was for medical clearance for day services at the mental health center. He complained of gaining weight and difficulty sleeping. Initial evaluation included vital signs, weight, and routine labs. DJ was diagnosed with hypertension. He was not aware of his elevated blood pressure and was educated to the effects of hypertension. DJ consented to taking medication and was taught how to record his Blood Pressure readings.

Consultation between the SMA nurse practitioner and the staff at the Mental Health Association led to weekly blood pressure monitoring. Further collaboration among his care team led to DJ achieving BP at goal within 3 months. Lifestyle changes also led to needed weight loss. DJ is now compliant with all his medications and has a renewed appreciation for the positive effects of a coordinated healthcare system that treats the whole person.

At Initial Visit At 1 Month At 3 Month
BP 188/106 176/104 144/90
Weight 221 lbs 215 lbs 198 lbs

Case Study 3

VS is a 56-year-old Hispanic male who was seen in the primary care clinic for an initial visit. VS had not been feeling well. An intake was taken by the medical assistant to include vital signs, weight, height, BMI, and medical history. The nurse practitioner performed a thorough medical exam and ordered routine labs, and cardiac imaging (Echocardiogram, Carotid doppler and arterial studies.) Routine physical exam was unremarkable except for a cardiac S3 gallop.

VS complained of excessive thirst and weight gain. Upon review of the labs blood glucose was 426, HgA1c was 9.3, Cholesterol 205, Triglycerides 678. Evidenced based protocol was put in place. VS was unaware of this condition. Medication for his Diabetes and high triglycerides were prescribed. VS was seen weekly for blood glucose monitoring and education. He was taught how to perform and blood glucose finger stick, read his blood glucose levels and eat a healthy diet.

At 3 months VS blood glucose was down considerably but his HgA1c was up. Further education was given including proper diet, portion control and medications adjusted. At 6 months blood glucose was 70 and HgA1c 6.4. VS visits now reveal controlled blood glucose, stabilization of HgA1c. His quality of life has improved.

At Initial Visit At 1 Month At 3 Month
BP 110/80 118/80 126/86
Weight 172 lbs 170 lbs 155 lbs
HgA1c 9.3 11.4 6.4