Complex Care in New Jersey Medicaid: Setting a Vision

3rd Annual GCC Conference

Josh Bamberger asks a question for Keynote, Frederick Isasi

September 19th, 2017  |  Trenton, NJ

With health care reform in and out of the national spotlight and a governor’s race approaching in November, national and state Medicaid experts, policymakers, and community members gathered in Trenton for the third annual Good Care Collaborative conference, Complex Care in New Jersey Medicaid: Setting a Vision. After hearing from panelists about bright spots of innovation across the country and state, the 130 attendees had the chance to write suggestions to the new state administration to advance complex care in New Jersey.

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Keynote Speakers

Toyin Ajayi, MD, MPhil
Chief Health Officer of Care Lab at Sidewalk Labs, where she is building personalized social care models for patients and communities with complex health and social needs. She is a true leader in designing, implementing, and evaluating clinical interventions to improve the quality, patient-centeredness, and cost of health care delivery in complex and multi-morbid patient populations. Previously, as the Chief Medical Officer at the Commonwealth Care Alliance (CCA) in Boston, MA, Toyin oversaw clinical delivery and clinical operations.


Frederick Isasi, JD, MPH
As Executive Director of Families USA, a leading national health care advocacy organization, Frederick pursues the goal of high-quality, affordable health care for all. In his previous roles, as Health Division Director for the National Governor’s Association Center for Best Practices and as Vice President for Health Policy at the Advisory Board Company, Frederick fought for health care service delivery and payment reform, state employee and retiree health benefits, maternal and child health, prescription drug abuse prevention, and health insurance exchange implementation.



This panel will highlight models of “good care” from across the nation, developed for the most medically and socially complex patients. We will learn how experts from these models have aligned stakeholders to build support and sustainability plans for these innovative, evidence based programs.

Moderator: Susan Mende, Senior Program Officer, Robert Wood Johnson Foundation

Michael England: OBGYN, The Pregnancy Recovery Center, Magee-Womens Hospital of UPMC

Emily Wang: Co-Founder, Transitions Clinic Network

Josh Bamberger: Physician Specialist, San Francisco Dept of Public Health

Renee Levesque: Care Coordination Manager, Hennepin Health



This panel will identify specific policy recommendations for advancing quality, outcomes, and efficiencies in the New Jersey Medicaid system for complex care. We will highlight the role of consumers in the advocacy process and how policy reform can support the development and advancement of innovative, evidence based models of care.

Moderator: Cindy Mann, Partner, Manatt Health

Linda Schwimmer: President and CEO, New Jersey Health Care Quality Institute

Heather Howard: Program Director, the State Health Reform Assistance Network, Princeton University

Marilyn Mock: Director of Social Services, Fair Share Housing Development

Allison Hamblin: Senior Vice President, Center for Health Care Strategies

Published on June 13th, 2017

Community-based ACOs: Powerful models to improve behavioral health

A Housing First patient in Camden, NJ in her new home.

A Housing First patient in Camden, NJ in her new home.

A recent report published by Rutgers identified that about 86 percent of the top 1 percent highest-spending Medicaid patients in our state suffer from a behavioral health diagnosis. Given these statistics, New Jersey’s three certified community-based ACOs recognize that addressing behavioral health issues in their local communities is a key component of their success. The Camden, Trenton, and Newark ACOs serve individuals who present with mental health and substance abuse issues at a significantly high rate—approximately 1 in 4 ACO patients has a behavioral health diagnosis.

Bringing community-based, coordinated care to complex patients in New Jersey, the three ACOs are advancing behavioral health initiatives in their communities.

  • The Housing First program for medical super users in Camden supports many individuals with mental health and substance abuse issues. Preliminary results of this program show a 40 percent reduction in hospital utilization.

  • Citywide quality improvement initiatives to increase access, capacity, and treatment options for patients suffering from mental health and substance abuse. Focusing on improving local access and provider capacity to write prescriptions for suboxone, a medication assisted treatment for opioid use.

  • Sharing protocols for patients with substance use issues in the ED. The Trenton ACO is working to develop shared protocols and procedures among their three area hospitals for patients presenting with substance abuse issues in the ED.

  • ACO data and technology infrastructure as well as its unique ability to convene multiple and competing stakeholders has allowed the Camden Coalition to serve a key role in the South Jersey Behavioral Health Innovation Collaborative (SJBHIC), which aims to improve the coordination and delivery of behavioral health care in the five participating south jersey hospitals.

The ACOs, their communities and patients have all deeply invested in the Demonstration Project and are committed to improving quality, outcomes and efficiencies in a highly complex and entangled Medicaid system. In the areas of behavioral health, we are beginning to see their promise. The three ACOs were able to use state funding to build and sustain important data and information infrastructure to support population health initiatives, support stakeholder engagement to allow for improved community-wide coordination and collaboration, and build capacity for city-wide and targeted quality improvement work. The ACOs need continued state funding to see the Demonstration Project through to completion and continue to build upon the good work, the data and quality improvements each has begun to see in their communities, especially in the area of behavioral health.

Published on April 24th, 2017

The Transformative Impact of New Jersey’s Medicaid Accountable Care Organizations

New Jersey's 3 Medicaid ACOs (Camden, Trenton, & Newark)

Thomas Edison University  |  Trenton, NJ

Thursday March 23

Last Thursday, on the 7th anniversary of the Affordable Care Act (ACA), community leaders highlighted the promise of local models. A Medicaid Accountable Care Organization (ACO) is an evidenced-based model that aims to improve outcomes for individuals with complex health and social needs by improving the coordination and delivery of their care. The Good Care Collaborative convened providers, advocates, and policy leaders for a forum to discuss early impact and future implications of New Jersey’s community-based Medicaid Accountable Care Organizations.

Leaders from across the state shared lessons learned and discussed how this work can continue to reshape New Jersey’s health care landscape. With limited resources and increasing uncertainty at the federal level regarding the future of Medicaid, the Medicaid ACOs provide innovative, evidence based, regional approaches to improving quality, outcomes and efficiencies for vulnerable patients.
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Published on February 14th, 2017

Webinar: Behavioral Health Reform in New Hampshire


Behavioral Health Reform in New Hampshire: Implications for NJ

November 16, 2016

The Good Care Collaborative hosted a webinar featuring New Hampshire’s Medicaid Director Deborah Fournier, highlighting that state’s recent behavioral health care system reform. Relying on their 1115 Transformation Waiver, New Hampshire has been able to prioritize collaboration and a cultural shift in dialogue around care. Notably, New Hampshire’s Waiver process has allowed for the development of regional Integrated Delivery Networks (IDNs) that aim to strengthen community-based mental health services, combat the opiate crisis, and drive delivery system reform towards integrated care.

Similar to New Jersey Medicaid Accountable Care Organizations (ACOs), IDNs work to improve care transitions and relationships between providers. By organizing IDNs across 7 separate regions of care, New Hampshire has been able to address unique care needs at the community level while also allotting sufficient funding to each IDN to pursue their care goals. As Deb said, “it’s all about the data.” Data analysis has been key in this process from development of the IDN regions to assessment of community needs. The innovative tactics employed in this reform and the new system of care point to a future of better, more intentional care for the Medicaid population. The details of this reform process and the IDN structure are outlined in the slides below.

The webinar, moderated by Jocelyn Guyer of Manatt, Phelps & Phillips, LLP., was grounded by Julie Cannariato, Policy Director for the New Jersey Medicaid office, who provided an update on New Jersey’s current 1115 Waiver Renewal Application.

Download the NH 1115 Waiver PowerPoint

Watch the webinar here

Published on November 22nd, 2016

The 2nd Annual Good Care Collaborative Conference

 Panelists discuss models of integration across the country

Envisioning the Future: Behavioral Health in NJ

On May 10th, the Good Care Collaborative hosted its 2nd annual conference, Envisioning the Future: Behavioral Health in New Jersey. The conference provided the forum for patients, advocates, payers, providers, and policy leaders to come together to discuss the opportunities for reform to improve care and increase efficiency in our public behavioral health system.

A growing body of research identifies the importance of behavioral health and underscores that integrating behavioral health and medical care will lead to better access to care, healthier patients and communities, and lower treatment costs over time.  Continue reading

Published on May 15th, 2016