Margaux Bigelow, Senior Program Manager, Camden Coalition
Sheryl Mathis, Senior Director of Clinical Redesign Initiatives, Camden Coalition
Mark Humowiecki, Senior Director of the National Center for Complex Health and Social Needs, Camden Coalition
Special thanks to Sarah Aleman and Dr. Douglas Bishop from Zufall Health Center and Roger Borichewski, Donna Coyle, Linda Lanni, Vera Sansone, and LeeAnn Wagner from CPC Integrated Health for their support to ensure the accuracy and clarity of the information presented.
Amid shifting federal health care funding, grants that enable health care safety net entities[1] to respond to the changing landscape can unlock immense value. This form of grantmaking puts daily program-related decisions in the hands of people doing the work, allowing organizations to develop and sustain staff positions, workflows, and programs that reflect their priorities.
Behavioral health care safety net providers—Certified Community Behavioral Health Clinics (CCBHCs) and integrated care-focused community health centers—are vital resources for individuals with behavioral health needs, including substance use disorder (SUD) [2]. To address the full range of factors affecting this population’s health and well-being, these organizations require funding and technical assistance (TA) to improve and expand service provision, internal capacity, and cross-sector collaboration efforts. To help these organizations better serve their communities, the Bristol Myers Squibb Foundation (BMS Foundation), an independent charitable organization whose mission is to improve global health, launched a grant program called the New Jersey Safety Net Innovation Proposal (NJ SNIP).
New Jersey Safety Net Innovation Proposal
The NJ SNIP, launched in 2023, is a grant program funded by the BMS Foundation to strengthen the health care safety net in New Jersey, providing grants to nonprofit, community based mental health service providers caring for individuals living with serious mental illness (SMI). To ensure proper expertise, assistance, and oversight, the BMS Foundation provides funding to the Camden Coalition, a national leader in improving care for people with complex health and social needs, to serve as an implementation partner supporting the grantees within the program.
Awardees of the NJ SNIP grants receive funding for two years to address community and/or strategic capacity-building needs and increase access to quality health care for individuals living with SMI. The Camden Coalition provides tailored, organization-specific support for project management and implementation, as well as other informational and training resources.
Camden Coalition TA approach
The Camden Coalition’s TA for the NJ SNIP is client-driven, allowing the needs of the grantee to frame the engagement. This support mirrors the grantmaking approach, creating structure and accountability and enabling the grantee to meet evolving community needs.
The TA is rooted in an understanding that grantees’ work cannot happen in a vacuum: their programs need to operate within a strong, coordinated ecosystem of care [3] that improves the effectiveness, efficiency, experience, and quality of care. The Camden Coalition supports organizations across the six domains of a strong ecosystem: workforce, services, data & measurement, leadership & governance, payment & funding, and consumer participation.
Each grantee meets with the Camden Coalition quarterly to share progress on project objectives and activities, assess ongoing and newly available program data, review successes and challenges that TA or training can address, and plan for sustainability and community engagement. Rather than requiring grantees to participate in preset TA events or complete a standard curriculum, the Camden Coalition connects them to informational resources, evidence-informed curriculum, and subject matter experts based on needs that emerge during discussions.
The individualized TA sessions not only identify and address each organization’s unique needs but also give the Camden Coalition and the grantees time to develop a collaborative relationship, resulting in deeper discussions and strategy development related to their work. Grantees have described this experience as one built on mutual trust, with their expertise and knowledge of local community needs respected by the TA team.
The NJ SNIP grantee spotlight
Through the NJ SNIP, grantee organizations made progress in closing gaps in care through the creation of new staff positions, investments in workforce capacity through training, and building meaningful relationships and information-sharing processes with other health care and community organizations.
Zufall Health Center and CPC Integrated Health are two NJ SNIP grantees who leveraged funding and TA to transform their capacity to serve the most medically underserved residents in their respective communities.
Zufall Health Center
Zufall Health Center (Zufall) is a Federally Qualified Health Center (FQHC) with 14 locations across northern and central New Jersey. Through the NJ SNIP grant, Zufall established a holistic approach to serving patients with substance use disorders (SUD) by integrating Medications for Opioid Use Disorder (MOUD) and Medications for Alcohol Use Disorder (MAUD) into existing primary care and case management services.
During the grant period, Zufall merged with a local addiction medicine provider, bringing in more than 240 new patients, a physician with addiction medicine expertise, an addiction medicine coordinator, and a psychiatric nurse practitioner. Throughout this process, the Camden Coalition connected Zufall with subject matter experts with state-specific expertise on standing up office-based addiction medicine services and facilitated access to staff training through the Camden Coalition Learning Center. The funding, TA, and training helped Zufall transform into a multi-specialty practice capable of providing immediate, on-site access to office-based substance use treatment across their primary care programs.
Zufall’s integrated care model enables primary care providers to connect patients with addiction medicine specialists through same-day appointments, reducing wait times and minimizing care transitions – typically significant barriers to care. The organization also improved screening and triage processes for individuals using substances and standardized workflows across all their health center locations to better meet patient needs. Providers and staff can now access specialty providers as a resource when they need support in navigating substance use care with patients. Overall, Zufall has experienced a transformation in service capacity and culture, with staff demonstrating greater understanding of SUD and increased willingness to engage in addiction medicine care. The grant also gave Zufall the opportunity to strengthen collaborative relationships within the broader ecosystem, including hospitals, county jails, community-based substance use organizations, and specialty pharmacies to bridge gaps in care. When patients have social needs beyond what Zufall can support, the organization can rely on these new community partnerships for help. In turn, community organizations have recognized the value of Zufall’s integrated care model and increasingly refer clients to the FQHC for medical services, including behavioral health needs.
CPC Integrated Health
CPC Integrated Health (CPC) is a nonprofit Certified Community Behavioral Health Clinic (CCBHC) in Monmouth County, New Jersey. Through the NJ SNIP, CPC developed the BRIDGE program, which provides outreach, engagement, and care coordination to individuals living with SMI. The program aims to expand access and strengthen cross-system connections for people with complex needs by building referral pipelines, embedding staff at partner sites, and supporting workflows and data/reporting capacity.
The NJ SNIP funding has allowed the CPC BRIDGE program to develop innovative approaches to care by expanding access points to care. The grant funded two care manager positions who rotate between a mobile van unit, FQHC, social services office, and food pantries to perform on-site admissions to BRIDGE program services. This strategy enrolls people in the program through a trusted community partner or setting and streamlines access by reducing potentially challenging enrollment steps. Co-locating care managers in community settings also builds relationships with partner organizations and creates opportunities for bi-directional support and information-sharing between staff at both organizations. Since the start of the program, the care managers have engaged 155 individuals, and 99 people have been enrolled in CPC’s CCBHC services.
The Camden Coalition supported CPC’s care coordination and partnership development by helping the team address cross-organization information-sharing barriers through improved workflows and strengthened connections with their regional health information exchange (HIE). CPC staff also participated in Camden Coalition Learning Center trainings to build care delivery knowledge and skills.
Sustainable impact
The NJ SNIP represents a successful philanthropic investment that helped transform safety net organizations. While modest in size, the funding gives grantees the opportunity to address self-identified priorities at their organizations and in their communities by adapting to meet patients’ long-term needs. As a result, current grantees such as Zufall, CPC, and others have sustained and even scaled the work they began during the NJ SNIP funding cycle. The TA complemented the grant funding by guiding grantees through their specific challenges and teaching key skills in areas such as community engagement, data utilization, program development, and complex care delivery models that will be retained long after the NJ SNIP ends.
[1] The Alliance for Health Policy defines safety net providers as “health care providers who deliver health care services to patients regardless of their ability to pay. These providers may consist of public hospitals, community health centers, local health departments, and other providers who serve a disproportionate share of uninsured and low-income patients.”
[2] SAMHSA defines serious mental illness as someone over 18 having (within the past year) a diagnosable mental, behavioral, or emotional disorder that substantially interferes with a person’s life and ability to functions. SMIs include conditions like bipolar disorder, major depressive disorder, and schizophrenia.
[3] Ecosystems of care are local networks of organizations, health systems and practitioners, community members, payers, and other stakeholders, working collectively to address the root causes of poor health.