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Johnson & Johnson Integrated Care Project

About Zufall Health Center

Zufall Health is a 501(c)(3) Federally Qualified Health Center (FQHC) and trusted safety-net provider of high-quality affordable medical, dental and behavioral health care to more than 36,000 of the most vulnerable, underserved residents of northwestern and central New Jersey. Over the past two years, with funding support from Johnson & Johnson (J&J), Zufall has developed a viable model for behavioral health-primary care integration.

Zufall’s patients are among the most vulnerable residents of the region.

  • 56 percent have incomes below 100 percent of the federal poverty level (FPL)
  • 88 percent have incomes below 200 percent of the FPL
  • 37 percent are Medicaid beneficiaries
  • 6 percent are covered by Medicare
  • 48 percent have no third-party coverage
  • 9 percent are privately insured

Engaging more than 300 patients with serious mental illness (SMI) as primary medical care patients annually, Zufall has overcome critical access barriers such as lack of transportation in a suburban/rural service territory by using mobile medical and dental vans to serve isolated patients with SMI.

Partnership between Zufall Health Center and Saint Clare’s Behavioral Health

Since 2011, Zufall Health has partnered with Saint Clare’s Behavioral Health Centers to improve health outcomes of people with SMI, addressing the issues affecting this vulnerable, underserved population by providing critical patient navigation services.

A key component to the success of Zufall’s integrated care is a dedicated patient navigator (PN) who serves as a liaison between the primary care providers and the behavioral health clinical staff. The PN provides a dedicated presence at both Saint Clare’s Outpatient behavioral health centers and Zufall’s primary care offices, coordinating services and responding to the range of challenges that contribute to issues of non-compliance or impaired treatment adherence within this high-risk SMI patient population.

Working closely with Saint Clare’s behavioral health nurse coordinator, the PN effectively participates in daily communication between the two organizations, handling urgent patient needs expediently and participating in Saint Clare’s interdisciplinary team meetings to augment integrated communication between the two health service teams.
The PN has contributed to bringing well-integrated, comprehensive primary medical care and essential supportive assistance to this severely underserved population.

Patient Navigator as a Key Component of Integrated Care

Utilizing patient navigation as a tool to facilitate clinical integration between the mental health sector and the patient’s primary care medical home, SMI patient access to medical and oral health care has become significantly less fragmented and episodic with J&J’s continued support. The PN serves as a trusted advocate for behavioral health patients, established through years of integration and collaboration with the behavioral health team at the Saint Clare’s site.

The PN, using the Patient Navigation Intake Form, identifies patients served by the behavioral health program who need primary and specialty care services and facilitates scheduling for chronic conditions, medication refills, referrals and acute care visits.

While some SMI patients accept the offer of primary care services through Zufall (see Primary Care Assessment for example form), many identify as having their own primary care provider and remain committed to that community-based provider. This fact reinforces a key aspect of Zufall’s experience, specifically, that among the SMI population the importance of established relationships cannot be underestimated, as long-term relationships enhance a critically an important sense of trust in this patient population.

The PN is located in Saint Clare’s behavioral health site and is a trusted member of that team. The team is included in management and care of patients with co-morbid conditions. The PN is also part of Zufall’s in-house behavioral health team, attends clinical staff meetings and is part of the Zufall Quality Assurance/Practice Improvement (QA/PI) Committee.

Since health records are not integrated between Zufall and Saint Clare’s, a protocol was developed to ensure consistent communication between programs. The Fast Facts form is an example. In addition, the PN arranges for phone calls or written communication between the assigned clinicians for specific issues that warrant additional discussion.


As an additional step in providing a fully accessible comprehensive system of care, Zufall has “co-located” primary care providers at Saint Clare’s behavioral health sites via a mobile medical van that parks in front of the behavioral health center to provide physicals, screenings and routine follow-up to patients. This has greatly increased access for behavioral health patients who would otherwise need to travel to the health center for routine issues.
Zufall has continued to explore best practices for bringing our mobile services to the vulnerable behavioral health populations to limit transportation barriers to a greater degree. Our mobile van services have facilitated additional layers of programmatic efficiency, convenience, and effectiveness in meeting the needs of the SMI population.

Zufall’s PN has brought a consistent, trusted presence to the roll-out of van services. This established relationship has been a key factor in paving the way for integration of primary care services with the SMI population.

Workforce Development

Zufall has an array of workforce development strategies to support integration that include:

  • Loan forgiveness for providers with outstanding loans for post-graduate education.
  • Flexibility in scheduling and hours.
  • Participation in community events and in innovative programs such as providing care to patients in rural areas on mobile vans.
  • Leadership development in areas of interest or expertise such as quality assurance and teaching.
  • Incentive compensation program.
  • Extensive staff support such as medical assistants who help with translation, documentation, tracking and follow-up of patients.
  • Quarterly grand rounds at the site with Continuing Medical Education (CME) credits offered.
  • Frequent staff and clinical meetings to enhance communications and feeling of belonging.
  • Scheduled training opportunities for different staff to further develop their knowledge and skills.
  • Periodic activities that focus on topics like physician engagement and provider burn-out.

Leadership is committed to workforce development and retention and looks closely at pay and benefits to provide a balanced and competitive employment.

Population Health Management

Zufall analyzes data from our electronic medical record (EMR) and information shared by Saint Clare’s to make primary care decisions on an individual basis. Patient-specific data is then used to focus services via our mobile van or through a health center visit. Over time, we have seen that the cohort of patients collocated at Saint Clare’s Behavioral Health have seen improvements in hypertension and diabetes control, and in cervical cancer screening rates (from 2013 to date).

General quality improvement activities at Zufall focus on more than 20 clinical measures and outcomes, and patients receiving behavioral health services are included in the population health reports that Zufall submits to its funders, the federal government and accrediting organizations. Examples of these clinical measures include universal depression screen and referrals, Screening, Brief Intervention and Referral to Treatment (SBIRT) rates, body mass index (BMI) and counseling on nutrition and physical activity, tobacco use screening and cessation counseling, cervical and colon cancer screening, hypertension and diabetes control, among many others.

Key Considerations and Lessons Learned

Successful integration is a challenging process. Throughout our journey, Zufall learned an array of lessons that may be useful to an organization intent on beginning on this path.

  • Patient volume is a critical factor in determining the fiscal sustainability of an integrated primary care/behavioral health program. For Zufall, given the relatively small size of the patient population in any of the local behavioral health agencies with which Zufall partners, it has not been cost-effective to develop a high-quality, primary medical care service collocated within a behavioral health site. Ultimately, Zufall found that behavioral health programs could not consistently produce enough client volume to warrant such allocation of resources.
  • Due to the SMI patient’s limitations (e.g., psychological, psychosocial, myriad of access barriers), this population and their caregivers require extensive time over which to build trust and identify with an organization or care provider. Routine care and continuity are significantly more critical in this setting and with this population than in other environments and with other target populations. Introduction of new staff and/or services is a lengthy process. Accordingly, a consistent, full-time or near full-time staff presence is necessary.
  • An assessment for identifying primary care needs at behavioral health partner organization is critical to ensure proper care coordination.
  • State licensure and regulatory requirements play a major role in the feasibility of physically integrated services. New Jersey requirements for both primary medical care and behavioral health services facilities have presented a significant barrier to collocation of services. Advocacy by the provider community appears to be having an impact and the state is now reviewing and revising policies that hinder integration.
  • While primary care visits to SMI patients are sustainable in that they are reimbursable through Medicaid, Medicare and Charity Care, a PN’s salary is grant-dependent. This presents a core challenge to the program’s overall sustainability. We continue to seek grant support for this essential and cost-effective intervention.
  • Data sharing is key to identify gaps in care. Provision of comprehensive care requires information from primary care providers (PCPs) or other providers and requires close coordination, business agreements and data sharing capability. The Jersey Health Connect Health Information Exchange Data Viewer Agreement is an example of a data sharing agreement.
  • While the need among SMI patients is significant, in practice the challenges of establishing productive, consistent primary care relationships can thwart the process in the attempt to bring two separate organizational entities together to serve the population collaboratively.
  • For more information, check out Zufall Health Center’s Integrated Behavioral Health and Primary Care Change Package.

Return to the Johnson & Johnson Integration Project page.