FY 2024 Behavioral Health Service Expansion - Saint James Health (SJH) proposes to use Behavioral Health Service Expansion (BHSE) funding to provide expanded screening, diagnosis and treatment of mental health (MH) issues, substance use disorder (SUD) issues, and opioid use disorder through appropriate medications (MOUD) experienced by unserved and underserved residents in our Greater Newark NJ service area. SJH has already made significant progress integrating on-site behavioral health (BH) into medical care and removing barriers. BHSE will fill in remaining gaps to serve 400 unduplicated patients (335 MH and 118 SUD) by the end of 2025. Needs. In the SJH service area, Essex County (including Newark) has the highest prevalence of undiagnosed and untreated MH issues, SUD and opioid use in New Jersey (NJ). Rates are documented in BH needs assessments of NJ Departments of Human Services (2022) and Health (2022) and Newark EMA for people living with HIV (2023). Needs are highest among lowest income residents, due to stigma, denial, lack of health insurance and language/cultural barriers. The BH system is fragmented among agencies: hospitals, emergency departments, specialty care, Certified Community Behavior Health Centers (CCBHCs), health centers and community agencies. Fragmentation is worsened by NJ state facility licensing requirements for two separate licenses for ambulatory care and mental health from two state departments before a health center can treat both medical and behavioral needs in a single location. The high cost of bilingual licensed professionals – psychiatrist to prescribe medications and Licensed Clinical Social Worker (LCSW) to treat both MH and SUD – results in Spanish-speaking populations not being treated. Populations. SJH BHSE will serve low income residents-primarily adults and their families, most of whom are racial/ethnic minority – Black/African American and Hispanic/Latino – with many best served by a language other than English (Spanish). Proposed services. With BHSE funds SJH will provide an integrated care system for patients and service area residents through a convenient, culturally appropriate single entry point. BHSE funded services will be provided at our three clinic locations in Newark’s East, West and South Wards. The East Ward site is already licensed for MH; MH licensing is being finalized for the West and South sites. SJH will immediately hire a Certified Psychiatric Nurse Practitioner (Psych NP) and three LCSWs with bilingual capability to diagnose and treat MH and SUD. They will rotate at the three sites. The Psych NP and SJH Medical Director will prescribe needed medications to treat OUD. BHSE will fund both training for SJH staff on BH protocols/practices, and peer support specialists for treatment compliance. SJH referral systems are in place for needed BH care and coordination. In 2022 SJH began collaborating with New Jersey’s largest health care system – Robert Wood Johnson/Barnabas (RWJB) – to create a medical and BH care continuum between RWJB hospitals, emergency departments, specialty care, and the SJH health center– to ensure appropriate care and continuity. Referral agreements are already in place and will be expanded to include BH services. The EPIC EMR is used throughout the RWJB system and at SJH which means one single patient chart for BH – further removing patient care barriers and improving care coordination. The RWJB/Trinitas renowned BH specialty care practice in Elizabeth NJ adjacent to Newark will receive referrals of appropriate patients as will Integrity House, a CCBHC in Newark. SJH case managers and enter into EPIC Social Determinants of Health (SDOH) for each patient, which are used for referrals to needed community services. Individual Health Related Social Needs (HRSNs) will be added. BHSE services and outcomes will be monitored by an updated Quality Management Plan and monthly performance review. Results will be shared with RWJB partners for system-wide improvement.