Integrity House is one of the largest nonprofit addiction treatment organizations in New Jersey. But to offer cancer screenings and other basic primary care at the same site as it provides mental health and substance-use disorder services, Integrity House needed to get three separate state facilities licenses.
Those three licenses — issued by two separate state departments — come with different regulatory requirements governing things like where patient records are stored and how often state officials must inspect the facility. The regulations also require Integrity House to maintain three separate entrances, president and CEO Robert Budsock explained.
“It is a really an inefficient process,” Budsock said of New Jersey’s current licensing system, which he said is complex and costly for nonprofits to navigate. “And it is wrought with stigma,” he added, noting that the system seeks to separate people with psychiatric or substance-use diagnoses from primary care patients.
It also makes little clinical sense, Budsock said. “At Integrity House we’re treating the same person,” he said.
Budsock is among the three dozen stakeholders to sign on to a letter prepared by the New Jersey Health Care Quality Institute calling on the state Department of Health, which licenses most of the facilities involved, to address what advocates say is a long-standing barrier to more effective and better integrated care. They want the department to create a single outpatient license that would permit clinicians to offer primary care and behavioral health services — including mental health and addiction treatment — at the same location, which they said would allow for real-time collaboration on treatment plans and truly patient-centered care.
Integration is key
“Integrated care has the triple benefit of improving health outcomes, increasing access, and reducing stigma around behavioral health,” Linda Schwimmer, the president and CEO of the Quality Institute, a nonprofit policy group, wrote in the letter to Dr. Kaitlan Baston, the acting health commissioner. “Voluminous research over the past two decades has established that whole-person integrated care saves lives and allows those with behavioral health diagnoses to integrate fully into society.”
Baston — an addiction expert who ran a family clinic in Camden and launched a substance-use treatment program within Cooper University Hospital emergency room — was unavailable for comment, according to staff. “As a nationally renowned physician with expertise in providing integrated care including substance use disorder treatments to pregnant individuals, your commitment to integrated care is clear,” Schwimmer’s letter notes. Studies show the need for behavioral health services is significant nationwide and in New Jersey, with the COVID-19 pandemic exacerbating both psychological concerns and substance abuse. More than 40% of adults in New Jersey reported feeling anxious or depressed in February 2021, according to the National Alliance of Mental Illness, and 1 in 5 were unable to get counseling or therapy. Among tweens and teens, some 3 out of 5 were unable to get help for their depression, the alliance reported.
Some larger behavioral health organizations like Integrity House, which was founded in 1968 and treats some 3,000 people a year, and CarePlus, a nonprofit outpatient system based in Paramus, have navigated the licensing process to create facilities that offer truly integrated care. Federal funding for a Medicaid pilot program also enabled a handful of community-based health programs to expand their range of services, hours of operation and patient reach.
But widespread integration remains elusive in New Jersey. The Department of Health and the Department of Human Services — which regulates mental health and addiction services programs but not the facilities — have taken steps to better coordinate and integrate care over the years but efforts to create a single combined facilities license continue. “Health providers, and their patients, are ill-served by this fractured, conflicting system, when the care itself should be holistic, integrated and seamless,” Schwimmer wrote to Baston.
In 2015 health officials issued a waiver that allowed primary care offices to provide certain behavioral health services — if they also obtained key licenses from Human Services. But this waiver does not apply to mental health and addiction providers, like Integrity House, and advocates said the time and legal expenses needed for the application process make it inaccessible for many community-based organizations.
‘You can’t just single things out and treat them independently, because your physical health care is connected to your addiction care, which is connected to your mental health care.’ — Robert Budsock, Integrity House
In June 2017 former Gov. Chris Christie transferred the Human Services division that oversees mental health and addiction services to the Health Department under the banner of integrated care. A year later, Gov. Phil Murphy — whose transition team urged him to prioritize this issue — transferred part of the unit’s responsibilities back to Human Services, also in the name of integration.
In the final months of Christie’s second term, the Health Department had assembled an advisory panel to study barriers to integrated care. In December 2017 the department issued guidance announcing its intention to “reform its regulatory system to permit a single license for all three modalities of care,” according to the Quality Institute letter. At some point the department also created an integrated health services “branch” linking units that oversee behavioral care, community services and long-term resiliency with the goal of creating a “seamless system of care,” according to its vision statement. Christie also signed two laws directing the Health Department to take steps to advance integrated care, but as the Quality Institute letter notes, “No regulations responsive to either legislative mandate have been published in draft or final form.” It urges the department to “expeditiously resolve the remaining issues” and issue a draft of regulations permitting integrated care facilities.
“We’re moving toward integrated care and we know that it works,” Budsock said. “But the Department of Health, which handles the licensing, is not coming along with us.” Regulatory officials, he said, still treat different aspects of health care “like they’re in a silo.”
‘Unacceptable’ status quo
Budsock, Schwimmer and others acknowledge that reforming the licensing process is complex and an “issue that requires action and leadership,” according to the letter. But the status quo is “contrary to explicit legislative mandates and unacceptable from a public health perspective,” it notes.
Other signers include Jen Velez, a vice president at Horizon Blue Cross Blue Shield and former state official; Deborah Visconi, president and CEO of Bergen New Bridge Medical Center, a hospital that provides extensive behavioral health services; representatives of the Medical Society of New Jersey, the New Jersey Association of Mental Health and Addiction Agencies and other professional groups; and Seton Hall professor John V. Jacobi, whose 2016 report on the issue helped focus advocates on reform.
“In today’s world all care needs to be integrated and comprehensive,” Budsock said. “You can’t just single things out and treat them independently, because your physical health care is connected to your addiction care, which is connected to your mental health care.”