“Wrapping Around” Integrated Care

In 2014, Bergen’s Promise, Bergen County’s Care Management Organization within New Jersey’s Children’s System of Care (CSOC), took a bold step by agreeing to pilot a CSOC Behavioral Health Home; thus, establishing the first Pediatric Behavioral Health Home (BHH) in New Jersey and the first to utilize the Wraparound Model of Care in the United States. Wraparound is an individualized, team-based care planning and coordination process that develops a holistic treatment plan which includes supports for youth and families and oversees a process of goal setting and progress monitoring (Bruns et al. 2010). The establishment of a Child Family Team (CFT), incorporating youth/family strengths and family preferences, is the hallmark of this process. “Innovative” and “Promising”: Two words used to describe a blending of Integrated Care with the WrapAround Model of Care.

Bergen’s Promise BHH provides integrated care coordination to Medicaid-eligible youth, ages 5-21, experiencing emotional, behavioral, substance use and/or developmental challenges as well as designated chronic/physical health conditions such as asthma, diabetes, obesity, and endocrine disorders. The mission of Bergen’s Promise BHH is to provide increased care coordination via the Wraparound process and health/wellness activities for youth and their families to equip them with the knowledge, skills and confidence required to independently manage the demands of chronic health and wellness needs. Bergen’s Promise utilizes SAMHSA’s 8 Dimensions of Wellness to approach health and wellness holistically, and to address social determinants of health.

Working in partnership with the care manager and behavioral healthcare providers on each family’s CFT, the nurses and health educators of Bergen’s Promise BHH have helped families achieve significant outcomes. Over 80% of youth have improved their eating behaviors and over 60% have become more physically active. Over 70% of youth have reported improved self-esteem, and over 70% have reported improved health-related quality of life, which reflects physical, emotional, social and school-related wellness. Every school nurse and primary care provider of BHH enrolled youth are contacted and can become part of the team. Formal collaboration with pediatric primary care practices to facilitate seamless communication and coordination is advancing positive health outcomes in support of this Wraparound/ Integrated Care model.

Wraparound/Integrated Care Coordination has helped youth and families address challenges that involve the interplay of mental and physical health. For example, a child that worked with Bergen’s Promise BHH experienced anxiety about managing his asthma, which was further exacerbated by his diagnosis of generalized anxiety disorder. He and his family were able to work with the CFT to learn about his asthma and how to manage it while gaining skills to cope with his anxiety. As a result, the youth had a reduction in Emergency Room visits and improved emotional wellness. Additionally, an Asthma Action Plan, a written plan that is created with the youth’s medical provider, was given to the school nurse to ensure adequate, individualized care for his asthma. Certainly many youth with Intellectual/Developmental Disabilities (I/DD) and their families struggle with the continued silos of mental and physical health care; therefore, all those enrolled in Bergen’s Promise BHH have a Health Care Passport which is given to the School Nurse, Primary Care Provider and kept by the family should the youth need to go to the Emergency Room or Hospital. A description of how the youth communicates pain, emotional triggers, medications, diagnoses, food preferences etc. are provided for easy access to key information needed in a health emergency event. Wraparound/Integrated Care Coordination has also helped adolescents with Substance Use Disorders and their families coordinate mental, social and physical health concerns. For example, an adolescent with a substance use disorder worked with a health educator, behavioral health providers and primary care provider to holistically address areas of wellness that were impacted by her substance use. The youth demonstrated improved eating habits, reduced risk-taking behaviors, began regularly attending support meetings, obtained a high school equivalency diploma, got a job, and began saving money to plan for her future. These broad-based life-changing outcomes can be achieved through coordination of mental, social and physical health care coordination.

Based on the emergence of positive health outcomes of Wraparound/ Integrated Care Coordination embedded in Bergen’s Promise BHH, and with the understanding of risk factors that youth and families face in shaping their health status, Bergen’s Promise has adopted the metric that all its enrolled youth shall have a health and wellness goal incorporated into their Individual Service Plan. Bergen’s Promise believes that Integrated Care utilizing the Wraparound Model is uniquely fashioned to fit the developmental, social, emotional and health care needs of the youth and families it serves. A truly integrated system of care coordination can facilitate improved health outcomes, combat stigma and foster positivity, success and hope for all.

Acknowledgements: We thank Dean Pastras, Executive Director of Bergen’s Promise, for the opportunity to implement innovative practices within Bergen’s Promise Behavioral Health Home.

Shelisa Foster, MA, LPC, NCC, is Director of Operations; Amy Faus, MPH, CPH, CHES, is Health/Wellness Educator; and Jan Schlaier, Ed.D; FNP-BC, is Director of Health Services, at Bergen’s Promise. For more information, please visit www.bergenspromise.org.

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