Hackensack Meridian Health (HMH), in partnership with New Jersey Medicaid, New Jersey Health Care Quality Institute and the Visiting Nurse Association of Central Jersey, has entered into a collaborative agreement with Centers for Medicare and Medicaid Services (CMS) to establish the NJ Integrated Care for Kids (InCK) model. Working with those who provide primary care to children in Monmouth and Ocean Counties, NJ InCK will test an Alternative Payment Model (APM), for NJ Family Care programs, by providing payment for screening and provision of integrated community-based core child health services.



The Goals of the InCK Model Are:

Ensure that all children receive expanded EPSDT (Early Periodic Screening, Diagnosis, and Treatment) care at least annually;

Identify children and adolescents who have more complex health, behavioral or social needs; and

Provide community-based care management that integrates with the pediatric health system.

NJ InCK’s approach emphasizes the development of community-based case management and screening capacity and the use of Advanced Case Management Teams (ACMT) for children and families who are at the highest risk for health complexity. These Teams are structured to wrap around the patient’s on-going primary care at a community-based setting and will partner with the family and community organizations to create and implement a comprehensive care plan to meet the family’s identified needs. Information sharing amongst all of the patients’ health care providers and the Teams will be provided via the development and implementation of a robust health information exchange and population health platform.


The NJ InCK Model will include: integrated advanced case management, care planning, and community health workers. When gaps in population-based services are identified, NJ InCK will advocate for new clinical modalities. The NJ InCK Model will increase flexibility for selecting treatment modalities for adolescent substance use disorder.

Alternative Payment Model:

NJ InCK’s APM blends base funding and incentive payments to support eventual implementation of a shared savings APM built on New Jersey’s managed care program. The APM will incentivize higher screening rates to support appropriate patient stratification, connection to needed services, and intensive case management for high-needs children.

Community Partners:

In addition to the three co-lead organizations, additional project partners include the New Jersey Chapter of American Academy of Pediatrics and the Central Jersey Family Health Consortium. The project will also engage with a Partnership Council consisting of entities including local health departments, stakeholder representatives, Medicaid managed care organizations, and providers responsible for core child services, including physical and behavioral clinical care, schools, housing authorities, food support services, early care and education, Title VI agencies, child welfare, and mobile crisis response services

For more information contact Kate Shamszad at kshamszad@njhcqi.org.

This NJ InCK project is supported by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $9,988,970 as of 2023 with 0% percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CMS, HHS or the U.S. Government.